Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
  You asked the Plan to pre-approve additional non-emergency transportation. You say that you were never 
picked up for about five or six trips, and you would like all of those trips back. You also say that you can 
hardly walk and have no money to be paying out of pocket to get a ride to appointments. The Plan denied your 
request. The Plan says the requested complimentary non-emergent transportation benefits, above the allotted 
100 one-way trips per calendar year, are excluded from coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retinal screening photography (S9986), a medical 
examination (92012), a determination of refractive state (92015), progressive lenses (V2781), polycarbonate 
lenses (V2784), miscellaneous vision services (V2799), anti-reflective coating (V2750), photochromatic tint 
(V2744) and standard frames (V2020) provided on April 18, 2023. 
 
You asked the Plan to pay for retinal screening photography (S9986), a medical examination (92012), a 
determination of refractive state (92015), progressive lenses (V2781), polycarbonate lenses (V2784), 
miscellaneous vision services (V2799), anti-reflective coating (V2750), photochromatic tint (V2744) and 
standard frames (V2020). You say that you were told the insurance would pay for the frame and eye 
examination. The Plan denied your request. The Plan says you do not have out-of-network benefits under the 
Plan vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers vision services when they are provided within the network. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use a Plan vision network provider. 
The Plan rules also say that you are responsible for all eyewear costs from providers outside of the Plan vision 
network. The record shows that the provider you obtained these services from was not in-network with the Plan 
vision network at the time services were rendered. Based on this information, we decided that the Plan's rules 
for coverage of retinal screening photography (S9986), a medical examination (92012), a determination of 
refractive state (92015), progressive lenses (V2781), polycarbonate lenses (V2784), miscellaneous vision 
services (V2799), anti-reflective coating (V2750), photochromatic tint (V2744) and standard frames (V2020) 
have not been met. Therefore, we decided that the Plan does not have to pay for retinal screening photography 
(S9986), a medical examination (92012), a determination of refractive state (92015), progressive lenses 
(V2781), polycarbonate lenses (V2784), miscellaneous vision services (V2799), anti-reflective coating 
(V2750), photochromatic tint (V2744) and standard frames (V2020) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says that the Medicare criteria was not met. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a continuous glucose 
monitor (CGM).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 05, 2022, to 
September 03, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on August 05, 2022, to September 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 dental services provided on December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of abdomen and pelvis 
provided on January 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the computed tomography (CT) scan. You say that the services were medically 
necessary.  The Plan denied your request. The Plan says non urgent services should be from network providers 
who are contracted with the health plan.  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 the computed tomography (CT) scan of abdomen 
and pelvis provided on January 16, 2023, 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 medical eye examination, fundus photography, a visual 
field examination, diagnostic imaging, and a diagnostic ultrasound provided on January 05, 2023. 
 
You asked the Plan to pay for a medical eye examination, fundus photography, a visual field examination, 
diagnostic imaging, and a diagnostic ultrasound. You say that you are appealing with supporting records. 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 medical eye 
examination, fundus photography, a visual field examination, diagnostic imaging, and a diagnostic ultrasound 
provided on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection with moderate sedation. 
 
You asked the Plan to pre-approve the injection with moderate sedation. You say that you have severe back 
pain and need the injections. The Plan denied your request. The Plan says a sacroiliac joint injection with 
moderate sedation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that use of moderate or deep sedation, general 
anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for sacroiliac joint 
(SIJ) injections and therefore not considered medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection with moderate sedation have not been met. Specifically, the use of moderate sedation 
with sacroiliac joint injections is not considered medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac joint injection with moderate sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapies (97012) and the office visit 
(99202) provided from February 9, 2023, through March 29, 2023. 
 
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 the services at issue are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapies (97012) and the office visit (99202) 
provided from February 9, 2023, through March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Phillps Lifeline home medical alert system. 
 
You asked the Plan to pre-approve a Phillps Lifeline home medical alert system. You say that the service is 
necessary. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are emergency 
communications systems and do not serve a diagnostic or therapeutic purpose. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Phillps Lifeline home medical alert system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Phillps Lifeline home medical alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 2, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not know much about the service or 
drug that was billed every day that you were in the hospital. The Plan denied your request. The Plan says that 
self-administered drugs do not fall under Medicare Part B coverage. 
 
  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 pay for self-administered drugs provided 
on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) and anti-reflective coating 
(V2750) provided on February 6, 2023.  
You asked the Plan to pay for progressive lenses (V2781) and anti-reflective coating (V2750). You say that 
you have had progressive lenses since you started wearing glasses in your forties. The Plan denied your 
request. The Plan says the service is a covered benefit, but the enrollee has exceeded limits set in your 
agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $130 for one frame with standard lenses covered in full every 12 months. 
 
We looked at the file and the Plan's rules. The Plan rules say that they pay up to $130 for one frame with 
standard lenses covered in full every 12 months. The record shows this benefit has been exhausted with this 
service. Based on this information, we decided that the Plan's rules for coverage of progressive lenses (V2781) 
and anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not have to 
pay for progressive lenses (V2781) and anti-reflective coating (V2750) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic-porcelain/ceramic (D6245) and retainer crown  
porcelain/ceramic (D6740) provided on May 24, 2023. 
 
You asked the Plan to pay for a pontic and retainer crown. 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 pay for pontic-
porcelain/ceramic (D6245) and retainer crown  porcelain/ceramic (D6740) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation for sedation (D9219) and the deep sedation 
(D9223) provided on March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed an implant done and the anesthesia 
was required to do the dental procedure. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the evaluation for sedation 
(D9219) and the deep sedation (D9223) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional image (D0230) and a 
core buildup (D2950) provided on March 8, 2023. 
 
You asked the Plan to pay for 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 intraoral- periapical each additional image was exhausted on date of service March 8, 2023. Therefore, we decided that the Plan does not have to pay for intraoral- periapical each additional 
image (D0230) and a core buildup (D2950) provided on March 8, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the upper extremity. 
 
You asked the Plan to pre-approve an MRI. You say that you are experiencing severe pain and require an MRI 
to assist with diagnosis. The Plan denied your request. The Plan says that the request does not meet the 
Medicare requirements to be approved. 
 
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 pre-approve an MRI. Our reviewer says that the 
requested MRI meets the criteria for approval. Our physician reviewer found you have received a course of 
steroids with no relief or improvement in symptoms. This constitutes a red flag, and an MRI of the right 
shoulder should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on April 10, 
2023. 
 
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.  
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene 
instructions (D1330) provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010) provided on April 18, 2022. 
 
You asked the Plan to pay for surgical placement of implant body. 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 pay for surgical 
placement of implant body: endosteal implant (D6010) provided on April 18, 2022.