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

 
We decided that the Plan does not have to pay more for panoramic radiographic image (D0330), limited oral 
evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), each additional 
radiographic image (D0230), and office visit - after regularly scheduled hours (D9440) provided on April 21, 
2023. 
 You asked the Plan to pay more for the dental services. You say that you were referred to the out-of-network 
provider. 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 says 
your benefit for the requested services $2,000 dollar limit was met. The Plan also says that the office visit - 
after regularly scheduled hours 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, certain limitations apply. The record 
shows your benefit for the dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $2,000 towards the cost of dental services provided in 2023. This included a partial payment 
of $662.15 towards the dental services dispute. Once this partial payment was made, the yearly benefit 
maximum was reached. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 panoramic radiographic image (D0330), 
limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), each 
additional radiographic image (D0230), and office visit - after regularly scheduled hours (D9440) provided on 
April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dispensing fee (V5160) and the hearing 
aids (V5261) purchased on July 13, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial payment. The Plan denied your request. The Plan says these items are not payable as they 
were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the dispensing fee (V5160) and the hearing aids (V5261) purchased on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary denture. 
 
You asked the Plan to pre-approve the dental services. You say that these dentures 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 December 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary denture.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service December 15, 
2022, to December 19, 2022. You asked the Plan to pay for the billed services. You say that your claim should not be denied for a late NOA. 
The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 15, 2022. A valid NOA was not received by the Plan until 
January 19, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service December 15, 2022, to December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 80 additional units of G0277 and 20 additional units of 
99183. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation supports that this enrollee is suffering with a necrotic wound to the left 
foot requiring surgical amputation. It is also noted that the enrollee has undergone at least 32 visits of 
hyperbaric oxygen therapy so far. 160 units of GO277 and 40 units of 99183 have already been authorized by 
the health plan.  Despite undergoing prior hyperbaric oxygen therapy, the enrollee developed a necrotic wound 
which required surgical intervention. It is also noted that the enrollee suffers with arterial vascular disease. It is 
unclear whether the current hyperbaric oxygen therapy is efficacious, as the enrollee developed a necrotic 
wound while undergoing hyperbaric oxygen therapy. 80 additional units of G0277 and 20 additional units of 
99183 are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 80 additional units of G0277 and 20 additional units of 99183.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on January 12, 2023. 
 
You asked the Plan to pay for the consultation. You say that you had a problem with your tooth and your 
regular dentist found decay in it and advised it should be extracted. You also say that you went to get a second 
opinion from an endodontist. The Plan denied your request. The Plan says service D9310 is not included in the 
list of covered 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on December 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should not have to pay for the billed 
services, because your provider did not explain you would owe anything. 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 $202 on date of service April 20, 2022, $75 on date of service November 2, 2022, and 
$1,223 on date of service December 20, 2022, which is the annual maximum of $1,500 ($202 + $75 + $1,223 = 
$1,500). After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, 
your benefit for was exhausted on date of service December 20, 2022. Therefore, we decided that the Plan does 
not have to pay more for the dental services provided on December 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the neck and an ultrasound of 
the head and neck. 
 
You asked the Plan to waive the copayment for a CT scan and an ultrasound. You say that you are on a fixed 
income and cannot afford to pay this. 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 $200 
copayment for each CT scan. Your contract with the Plan also clearly says that you must pay a $40 copayment 
for other outpatient diagnostic tests by a specialty physician.  You have been asked to pay $200 for a CT scan. This item/service falls within the CT scan benefit category. 
You have also been asked to pay $40 for an ultrasound. This item/service falls within the other outpatient 
diagnostic tests benefit category. The total you owe is $240 ($200 + $40 = $240). 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 a CT of the neck or for an ultrasound of the head and neck performed on June 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tined lenses and the frames provided on May 1, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the tined lenses and the frames . You say that you should be reimbursed more for 
the eyewear. The Plan denied your request. The Plan says authorization was not obtained. 
 
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 
tined lenses and the frames. We found no exception that would require the Plan to pay for the tined lenses and the frames. Therefore, we decided that the Plan does not have to pay for the tined lenses and the frames 
provided on May 1, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided by an out-of-network provider on 
January 26, 2023, and April 13, 2023. 
 
You asked the Plan to pay for the foot orthotics. You say that the foot orthotics were medically necessary, and 
the Plan is just denying the claims. The Plan denied your request. The Plan says the rendering provider is not a 
Medicare certified provider. 
 
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 foot orthotics provided by an out-of-
network provider on January 26, 2023, and April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
March 28, 2023.  
 
You asked the Plan to issue reimbursement 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 payable as 
they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider. 
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration and bone replacement graft 
(D7953, D4266) provided on March 24, 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 guided 
tissue regeneration and bone replacement graft (D7953, D4266) provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user-adjustable heel height feature (L5990). 
 
You asked the Plan to pre-approve a user-adjustable heel height feature. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary. 
  A user-adjustable heel height feature is not reasonable and necessary. Therefore, we decided that the Plan does 
not have to pre-approve a user-adjustable heel height feature (L5990).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen (HBO) therapy treatments. 
 
You asked the Plan to pre-approve HBO therapy. You say that the service should be covered. The Plan denied 
your request. The Plan says the enrollee does not have a covered diagnosis for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that HBO therapy is not covered for any indication 
other then those listed in the Medicare rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HBO therapy have not been met. Specifically, the enrollee does not have a covered indication for 
this service. Therefore, we decided that the Plan does not have to pre-approve Hyperbaric Oxygen (HBO) 
therapy treatments.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total right hip arthroplasty. 
 
You asked the Plan to pre-approve the total right hip arthroplasty . You say that  the surgery is medically 
necessary.  The Plan denied your request. The Plan says the total right hip arthroplasty is not medically 
necessary. The Plan says the enrollee has not completed a minimum of six weeks of supervised physical 
therapy.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the total right hip arthroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has not completed six weeks of physical therapy for the right hip, based 
on the documentation provided for review. Detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident for the right hip. There is 
no indication of any physical therapy and/or injections having been trialed. Additionally, the enrollee has other 
plausible causes of pain. Formal diagnostic imaging studies were not provided to corroborate the provider 
noted pathology in the right hip. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total right hip arthroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the total right hip arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker. 
 
You asked the Plan to pre-approve a heavy-duty walker. You say that the item should be covered. The Plan 
denied your request. The Plan says insufficient information was submitted to determine medical necessity of 
this item. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a heavy-duty walker have been met. Medical records were not submitted.. Therefore, we decided that the Plan does not have to pre-approve a 
heavy-duty walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 miles for routine transportation 
(A0170). 
 
You asked the Plan to pre-approve an additional 100 miles for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 60 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, an additional 100 
miles would exceed the allowed limit. Therefore, we decided that the Plan does not have to pre-approve an 
additional 100 miles for routine transportation (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks are considered experimental/ investigational in nature. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam computed tomography (CT) scan, cleaning, and 
endosteal implant (D1110, D6010, D0367) provided on May 16, 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 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 cone beam computed tomography (CT) scan, cleaning, and endosteal implant (D1110, D6010, 
D0367) provided on May 16, 2023.