Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care/detoxification 
services provided from December 8, 2022, through December 15, 2022.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital 
care/detoxification services provided were not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that when the high probability or occurrence of medical 
complications (e.g., delirium, confusion, trauma, or unconsciousness) during detoxification for acute 
alcoholism or alcohol withdrawal necessitates the constant availability of physicians and/or complex medical 
equipment found only in the hospital setting, inpatient hospital care during this period is considered reasonable 
and necessary and is therefore covered under the program. 
 
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 acute inpatient psychiatric hospital 
care/detoxification services. Our reviewer says that the acute inpatient psychiatric hospital care/detoxification 
services provided were not medically necessary. Our physician reviewer found that the enrollee did not have 
any delusions, auditory/visual hallucinations, or any aggressive behaviors. The enrollee was not showing any 
withdrawal symptoms. The enrollees Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score  
was 2. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the enrollees condition or were for the purpose of a diagnosis. The health plans denial 
of continued inpatient psychiatric hospital care/detoxification services appears appropriate. The enrollee could 
have been treated in a lesser restrictive setting. 
                                                                                                                             
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 acute inpatient psychiatric hospital care/detoxification services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient psychiatric 
hospital care/detoxification services provided from December 8, 2022, through December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the root canal and the $10 copayment for 
the limited oral evaluation. The pulp vitality tests (D0460) intra-orifice barrier (D3911), treatment of root canal 
obstruction, non- surgical (D3331) are not a covered service provided on April 27, 2023. 
 
You asked the Plan to waive the cost share for  these dental services. You say that this should be covered. 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 50% 
coinsurance for dental services.  
 You have been asked to pay 50% coinsurance for the root canal and a $10 copayment for the limited oral 
evaluation. These items/services fall within the dental 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 cost share for  pulp vitality tests (D0460) intra-orifice barrier (D3911), treatment of root canal 
obstruction, non- surgical (D3331), root canal, molar # 31 (D3330) and a limited oral evaluation (D1040) 
provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral 
complete series of radiographic images (D0210), an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions (D0431), an adult prophylaxis (D1110), 
and a resin-based composite (D2391) provided from April 3, 2023, to May 15, 2023. 
 
  You asked the Plan to pay for the dental services. You say that the provider failed to let you know after you had 
been a patient for a couple of years and after you had work done that they were no longer in-network with the 
Plan. 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), an intraoral complete series of radiographic images 
(D0210), an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including 
premalignant and malignant lesions (D0431), an adult prophylaxis (D1110), and a resin-based composite 
(D2391) provided from April 3, 2023, to May 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided by an out-of-network 
provider from June 14, 2022, to July 25, 2022. 
 
You asked the Plan to pay for the home health care services. You say that the services were medically 
necessary, and you would like to be reimbursed. The Plan denied your request. The Plan says the rendering 
provider has opted out of the Medicare program. 
 
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 home health care services provided 
by an out-of-network provider from June 14, 2022, to July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory blood draw in a facility provided on May 03, 
2023. 
 
You asked the Plan to pay for a laboratory blood draw in a facility. You say that this patient is in a facility, and 
you depend upon the facility staff for any verification or prior authorization. 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 laboratory blood draw 
in a facility provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on January 20, 2023. 
 You asked the Plan to pay for infrared therapy. You say that the claim should be reprocessed .The Plan denied 
your request. The Plan says that the provider is not a physician, physician assistant, nurse practitioner/clinical 
nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for infrared therapy provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an ophthalmologist visit, and an injection 
provided on August 10, 2022. 
 
You asked the Plan to waive the cost share for an ophthalmologist visit, and an injection. You say that you 
disagree with the cost share applied. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $35 copayment per visit to an ophthalmologist or 
optometrist for Medicare-covered vision care.  
 
You have been asked to pay $62.69 for an ophthalmologist visit, and an injection. This total includes $27.69 
coinsurance, which is 20% of the allowed amount for an injection ($138.45 allowed x 20% = $27.69), and a 
$35 copayment for an ophthalmologist visit. The injection falls within the Medicare Part B prescription drugs 
benefit category. The ophthalmologist visit falls within the vision 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 cost share for an ophthalmologist visit, and an injection provided on August 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extension on metal post in jaw - tooth/area: 
31(D6056x1). 
 
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 extension on metal post in jaw - tooth/area: 31(D6056x1).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate conscious sedation, first 15 
minutes and subsequent 15 minutes (D9239, D9243) and the surgical placement of implant body (D6010x2) 
provided from February 18, 2022, to July 29, 2022. 
 
You asked the Plan to pay for the intravenous moderate conscious sedation, first 15 minutes and subsequent 15 
minutes (D9239, D9243) and the surgical placement of implant body (D6010x2),. You say that the procedure 
to have bone removed from your jaw and implanted with cadaver bone was medically necessary to treat the 
infection and cure the abscess. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intravenous moderate conscious sedation, first 15 minutes and subsequent 15 minutes (D9239, D9243) and the 
surgical placement of implant body (D6010x2) provided from February 18, 2022, to July 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 15, 2023, and April 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency responders were able to accommodate you in your home on both dates. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 15, 2023 to April 13, 2023. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport provided on March 15, 2023, and April 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 3, 2023. 
 
You asked the Plan to pay for the ambulance services. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 9, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient procedure 
provided on April 17, 2023, to April 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network outpatient procedure. You say that this was not a 
procedure, it was a visit to cut away part of the prostate. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for advanced imaging services. 
 
You have been asked to pay a $250 copayment for an in-network outpatient procedure. This item/service falls 
within the advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network outpatient procedure provided on April 17, 2023, to April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wearable control (K0108) for a manual wheelchair. 
 
You asked the Plan to pre-approve a wearable control. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wearable control (K0108) for a manual wheelchair.
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 the services are medically necessary for the enrollee 
to receive intensive rehabilitation and physician oversight. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses (V2783), variable asphericity lenses (V2430), anti-
reflective coating (V2750), photochromatic tint (V2744), deluxe lenses (V2702) progressive lenses (V2781) 
frames (V2020) and a vision accessory or supply (V2797) provided on April 28, 2023. 
 
You asked the Plan to pay for lenses (V2783), variable asphericity lenses (V2430), anti-reflective coating 
(V2750), photochromatic tint (V2744), deluxe lenses (V2702) progressive lenses (V2781) frames (V2020) and 
a vision accessory or supply (V2797). You say that you were told you should not be billed. The Plan denied 
your request. The Plan says the maximum benefit has been exceeded. 
 
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 a $500 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules say that Plan coverage includes a choice of a $500 
benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). 
This benefit was exhausted on May 3, 2023. Based on this information, we decided that the Plan's rules for 
coverage of lenses (V2783), variable asphericity lenses (V2430), anti-reflective coating (V2750), 
photochromatic tint (V2744), deluxe lenses (V2702) progressive lenses (V2781) frames (V2020) and a vision 
accessory or supply (V2797) have not been met. Therefore, we decided that the Plan does not have to pay for 
lenses (V2783), variable asphericity lenses (V2430), anti-reflective coating (V2750), photochromatic tint 
(V2744), deluxe lenses (V2702) progressive lenses (V2781) frames (V2020) and a vision accessory or supply 
(V2797) provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364) provided 
on December 5, 2022. 
 
You asked the Plan to pay for cone beam CT. 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 cone 
beam CT capture and interpretation (D0364) provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of implant body (D6100), implant/abutment 
supported fixed denture for edentulous maxillary arch (D6114), guided tissue generation (D4266), bone 
replacement graft (D7953) and incisional biopsy of oral tissue  soft (D7286) provided on April 11, 2022, to 
November 30, 2022. 
 
You asked the Plan to pay for these dental services. 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 
removal of implant body (D6100), implant/abutment supported fixed denture for edentulous maxillary arch 
(D6114), guided tissue generation (D4266), bone replacement graft (D7953) and incisional biopsy of oral 
tissue  soft (D7286) provided on April 11, 2022, to November 30, 2022.