Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you do not agree with the decision 
and you request the stockings to be approved. The Plan denied your request. The Plan says the denial of 
authorization is correct, because the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you are appealing the denial of the upper and 
lower dentures as you have no teeth. The Plan denied your request. The Plan says your benefit for the requested 
services 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 dentures was exhausted on date of service May 26, 2020. Therefore, we 
decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on July 20, 2023, to August 
10, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support these services. 
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 skilled nursing facility 
provided on July 20, 2023, to August 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on November 21, 2022, to 
November 29, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you do not know why these services were not 
covered. 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 physical therapy 
provided on November 21, 2022, to November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for miscellaneous vision services (V2799), frames 
(V2020), and not otherwise classified vision services (V2199) provided on July 14, 2023.  
You asked the Plan to reimburse for miscellaneous vision services (V2799), frames (V2020), and not otherwise 
classified vision services (V2199). You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says you have already utilized the full benefit amount. 
 
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 reimburses $200 once every 12 months toward your purchase of eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that they will reimburse up to $200 once every 12 
months towards the cost of eyewear. The record shows this benefit was exhausted October 20, 2022. Based on 
this information, we decided that the Plan's rules for coverage of miscellaneous vision services (V2799), frames 
(V2020), and not otherwise classified (V2199) have not been met. Therefore, we decided that the Plan does not 
have to reimburse for miscellaneous vision services (V2799), frames (V2020), and not otherwise classified 
vision services (V2199) provided on July 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for trips to 
multiple places. The Plan denied your request. The Plan says you have exhausted your transportation services 
for the year. 
 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 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
trips. 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 12 additional routine 
transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D5214). 
 
You asked the Plan to pre-approve the dental service (D5214). You say that you would like to request 
reconsideration of the denied dental service and that the services requested are medically necessary. 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 March 5, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the dental service (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive periodontal evaluation (D0180), 
intraoral comprehensive x-rays (D0210), and an extraction of an erupted tooth or exposed root (D7140) 
provided from June 28, 2023, to June 29, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that when you called the dental provider, you 
were told they were in-network with the Plan. The Plan denied your request. The Plan says dental services from 
an out-of-network provider 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. 
 
 
  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 
comprehensive periodontal evaluation (D0180), intraoral comprehensive x-rays (D0210), and an extraction of 
an erupted tooth or exposed root (D7140) provided from June 28, 2023, to June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a Freestyle Libre 3. You say that the enrollee would benefit from a Freestyle 
Libre 3. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient or observation care, per day 
(99222) and the subsequent hospital inpatient or observation care, per day (99232) provided on January 28, 
2022 and January 31, 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 services provided are not payable as the 
claim was submitted untimely. 
 
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 these services was not filed until July 3, 2023. This means that more than one 
calendar year from the dates of service had passed before a claim was filed.  
  
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the initial hospital inpatient or observation care, 
per day (99222) and the subsequent hospital inpatient or observation care, per day (99232) provided on  
January 28, 2022 and January 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Magnetic resonance imaging, any joint of lower extremity 
(73721). 
 
You asked the Plan to pre-approve an MRI. You say that you have a cyst growing for over 6 years and when 
you I roll over on it, it is so painful and it's getting harder to do anything in my daily life even walk. The Plan 
denied your request. The Plan says that there are no indication of need for an MRI.  
 
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 you 
need this medical item. Our physician reviewer found your symptoms are increasing and hardness of mass 
increasing.  The requested MRI of the right hip without and with contrast should be approved to rule out 
liposarcoma. 
 
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 
a Magnetic resonance imaging, any joint of lower extremity (73721).  
 
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 more for complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on April 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that you needed to go 
to an in-network dentist in order to get the $500 per denture. You also say that you called several dentists for 
estimates and you went to a dentist that only charged you $2300 total. The Plan denied your request.  The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The Plan also says the coinsurance was appropriately 
applied to the dental services. 
 
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. Your contract with the Plan 
clearly says that enrollees must pay a 50% coinsurance for a complete denture - maxillary (D5110), and 
complete denture - mandibular provided out-of-network and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. 
 
For service D5110 the provider billed $1,065.00, and the allowed amount is $707.00. You are responsible for a 
50% coinsurance for this service. You are responsible for a coinsurance of $353.50 ($707.00 x 50%). For 
service D5120 the provider billed $1,065.00, and the allowed amount is $662.00. You are responsible for a 
50% coinsurance for this service. You are responsible for a coinsurance of $331.00 ($662 x 50%).  
 
You have been asked to pay a 50% coinsurance for the complete dentures. You have been asked to pay the 
difference between the out-of-network providers charges and the Plans payment. 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 pay more for the complete dentures. 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 pay more for complete denture - 
maxillary (D5110), and complete denture - mandibular (D5120) provided on April 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 18, 2022, to 
January 24, 2022. 
 
You asked the Plan to pay for the medication. You say that the provider made the charges on the Medicare side 
and needed to be processed on the pharmacy side. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan or any other Medicare payment system. 
 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 
from January 18, 2022, to January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that you would like a one-time exception. You also 
say the member is 91, does not have much time left, and her quality of life would be much improved with 
hearing aids. The Plan denied your request. The Plan says the service sought or obtained was or will be 
rendered by a provider who is not under contract with the Plan. 
 
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 when you obtain hearing aids from an in-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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for your 
doctor appointments. The Plan denied your request. The Plan says you have used a total of 35 trips for 2023 
and you only have 1 trip remaining. 
 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 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 6 
additional routine transportation trips for your doctor appointments.  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 6 additional transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation trips (A0120). 
 You asked the Plan to pre-approve the additional trips. You say that you have exhausted your trips with the 
plan and you do not have Medicaid trips available due to your partial Medicaid status. You also say that you 
are unable to make it to your appointments and you cannot afford to pay for rides out of pocket. The Plan 
denied your request. The Plan says your benefit only allows 72 routine transportation trips. 
 
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 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your appointments. 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 8 additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were told that your chiropractic visit had a $10 
co-pay whether you are in network or not. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from June 23, 2023, to July 5, 
2023, by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that the Plan's website says you are in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by the enrollees 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 dental services provided from June 23, 2023, to July 5, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you have not received new dentures for the 
last 20 years. 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 partial upper denture (D5213) on April 3, 2019; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 3, 2019. Therefore, we decided that the 
Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on June 20, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
  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 a cleaning 
(D1110) provided on June 20, 2023.