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, intraoral x-rays, bitewing 
x-rays, panoramic x-rays, and a cleaning (D0150, D0220, D0230, D0274, D0330, D1110) provided on January 
12, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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, intraoral x-rays, bitewing x-rays, panoramic x-rays, and a cleaning 
(D0150, D0220, D0230, D0274, D0330, D1110) provided on January 12, 2023, by an out-of-network (OON) 
provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on January 25, 2023. 
 You asked the Plan to pay for the hospital services. You say that the enrollee was not on hospice at the time of 
service. 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 services provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on April 28, 2023. 
 
You asked the Plan to pay for the implantable, insertable, and wearable cardiac device evaluation. You say that 
the services were medically necessary. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on April 07, 2023. 
 
You asked the Plan to pay for a telemedicine visit. You say that the enrollee was in a nursing home at the time 
services were rendered. 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 telemedicine visit 
provided on April 07, 2023.
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 April 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not refuse medical advice. You also say that you were okay because you had friends and family with you. 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 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 April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3020) and orthopedic footwear (L3216). 
 You asked the Plan to pre-approve foot orthotics. You say that you are appealing the denied foot orthotics. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the requested foot inserts (L3020) and orthopedic footwear (L3216) are not a covered insert 
or footwear for a person with diabetes, and you do not wear a leg brace. Although orthotics may be appropriate 
for you, neither Medicare nor the Plan provides coverage of the requested foot inserts or footwear. Therefore, 
we decided that the Plan does not have to pre-approve foot inserts (L3020) and orthopedic footwear (L3216).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #10. 
 
You asked the Plan to pre-approve the dental service. You say that you had a root canal done and you need to 
crown to go over the top to protect the tooth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because crowns are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) for tooth #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing - one to three 
teeth per quadrant (D4342), and complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you had an issue with the denture you 
received in August of 2022 and were told your benefits were reinstated since you returned the dentures. You 
also say that you would like to get new upper dentures and put all of these past troubles behind you. The Plan 
denied your request. The Plan says your benefit for the periodontal scaling and root planing - and complete 
denture - maxillary has already been exhausted. The Plan also says that the reinstated benefit was used on 
February 28, 2023 when the D5110 was performed. 
 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 periodontal scaling and root planing - one to three teeth per quadrant was exhausted 
on date of service February 23, 2023, and the complete denture  maxillary was exhausted on February 28, 
2023. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing 
- one to three teeth per quadrant (D4342), and complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #31. 
 
You asked the Plan to pre-approve the dental service. You say that you paid for the services and the dentistry 
charged it to the insurance. 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 the Plan paid for a crown (D2791) on august 27, 2019; therefore, your benefit for the requested item or 
service was exhausted on the date of service of August 27, 2019. Therefore, we decided that the Plan does not 
have to pre-approve a crown (D2750) for tooth #31.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 2, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you have sent the medical documentation so the 
claim can be reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot 
be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on May 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
and intraoral - periapical each additional radiographic image (D0230) provided on March 9, 2023. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image and each additional intraoral - 
periapical radiographic image (D0230) provided on March 9, 2023. You say that the dental office verified your 
insurance before you were seen. You also say that on the day of your appointment you were told all was good 
but now you are receiving a bill for the x-rays and you don't feel you should be responsible.  The Plan denied 
your request. The Plan says this service is not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image 
(D0230) provided on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and related supplies 
provided by an out-of-network provider on December 29, 2022. You asked the Plan to pay for the CGM and related supplies. You say that you would like the claim 
reprocessed with medical records. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
a continuous glucose monitor (CGM) and related supplies provided by an out-of-network provider on 
December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tonic Motor Activation System (TOMAC). 
 
You asked the Plan to pre-approve the TOMAC. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the device has been requested for the treatment of a motor function disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TOMAC have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Tonic Motor Activation System (TOMAC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the surgical 
removal of erupted tooth (D7210) for tooth #20 provided by an out-of-network provider on June 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist said it was necessary to remove the 
tooth right away and you could not wait for an in-network provider. 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 the panoramic radiographic image (D0330) and the surgical removal of erupted tooth (D7210) for 
tooth #20 provided by an out-of-network provider on June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Keytruda is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not 
FDA-approved. Keytruda is also not supported by one of the major drug compendia or by clinical research. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3216).  
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
(L3216).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided on April 26, 2023. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the doctor needed to do 
the evaluation in order to proceed with the dental work. The Plan denied your request. The Plan says this 
procedure is not covered under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation - new or established patient (D0180) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 20, 2023, and 
February 20, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the enrollee's 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 November 24, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee The Plan denied your request. The Plan says these services can be provided safely in an 
alternate setting. 
 
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 the enrollee does not require services that are currently not being offered at the acute 
care hospital. There are no services that the LTACH would offer that are not currently being offered. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341/D4342). 
 
You asked the Plan to pre-approve D4341/D4342. You say that you need the requested dental service. The Plan 
denied your request. The Plan says the requested dental service is 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing (D4341/D4342).