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

 
We decided that the Plan does not have to pay for occlusal guard (D9944), comprehensive oral evaluation 
(D0150), complete series of intraoral x-rays (D0210), adult prophylaxis (D1110) and topical application of 
fluoride varnish (D1206) provided from September 11, 2023, to September 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist stated before the service that they 
were in 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. Occlusal guards (D9944) are not a 
covered benefit under any circumstance. 
 
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, comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), adult prophylaxis (D1110) and topical application of fluoride varnish (D1206) are 
not covered under this benefit when received from an out-of-network provider. Occlusal guards (D9944) are 
excluded not covered under this benefit under any circumstance. Therefore, we decided that the Plan does not 
have to pay for occlusal guard (D9944), comprehensive oral evaluation (D0150), complete series of intraoral x-
rays (D0210), adult prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided from 
September 11, 2023, to September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on December 3, 
2021. 
 
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 the hearing aids 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 items was not filed until July 7, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to issue reimbursement for the hearing aids purchased on December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for first responder medical aid provided on June 30, 2023. 
 
You asked the Plan to pay for first responder medical aid. You say that the service was medically necessary. 
The Plan denied your request. The Plan says medical aid/assessment at the scene by a first responder is not 
covered by Medicare. 
 
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 June 30, 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 first responder medical aid provided on June 30, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454) 
provided on July 26, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the enrollee is homebound. You say that the 
enrollee was not able to leave their house to find a network provider. You also say that this service was 
medically necessary. The Plan denied your request. The Plan says prior 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454) 
provided on July 26, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and a garment. You say that any treatment 
other than what you ordered, will only delay good results, or even cause exacerbation on the enrollee. The Plan 
denied your request. The Plan says the enrollee must use network providers to get medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings provided on September 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 18, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings provided on September 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on August 16, 2023. 
 
You asked the Plan to pay for the bitewings. You say that you have submitted the medical records showing this 
was the only second image. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service February 14, 2023.  Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) 
provided on August 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment provided on  
May 3, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says under Medicare guidelines, this is 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 May 3, 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 provided on 
May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that you are requesting 
reconsideration stating the enrollee would benefit from a Synvisc series intraarticular injection for her bilateral 
knee osteoarthritis without the use of ultrasound guidance. The Plan denied your request. The Plan says the 
records show that the request procedure is one that is not the standard of care. To be reasonable and necessary, 
an item or service must not be investigational or experimental. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has left knee pain from osteoarthritis. She 
uses Tylenol and topical Ketamine for pain. She wears a brace. She has had intra-articular steroid injection as 
well as viscosupplementation. She had a diagnostic block of the genicular nerves and had 80% pain relief. This 
is considered experimental therapy. It is the subject of ongoing clinical trials. Therefore, the request is deemed 
not medically reasonable and 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 genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the medical supplies provided on August 
11, 2023. 
 
You asked the Plan to waive the coinsurance for the medical supplies. You say that the injection should be 
covered with the PET scan copay since the injection is required for the exam. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the medical supplies. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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. The total you owe is $1,038 ($5,190 allowed 
amount x 20% = $1,038). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
medical supplies provided on August 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resting transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve the TTE. You say that the requested service is necessary to establish a 
baseline of the enrollee's heart function. The Plan denied your request. The Plan says the records do not show 
that the enrollee has new or worsening symptoms. 
 
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 TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
in the absence of any apparent significant change in the patient's clinical condition, including signs, symptoms, 
or findings on physical exam. Clinical guidelines do not support repeating a TTE with no intervening change in 
clinical status or physical findings. Therefore, the reviewer found that the requested TTE is 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 TTE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a resting transthoracic echocardiography (TTE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral destruction by neurolytic agent for genicular 
nerve branches including imaging guidance (64624), and bilateral destruction by neurolytic agent for other 
peripheral nerve or branch (64640). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee is keen on this 
procedure for longer lasting pain relief. The Plan denied your request. The Plan says the services are considered 
experimental and therefore are not covered. 
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is experimental for knee pain. Therefore, the reviewer found that the requested genicular nerve block is 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral destruction by neurolytic agent for genicular nerve branches 
including imaging guidance (64624), and bilateral destruction by neurolytic agent for other peripheral nerve or 
branch (64640).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 has medical issues, but not complex enough to require the higher level of 
care provided in an LTACH. The requested LTACH services are not medically necessary, reasonable, and 
appropriate. 
 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 10, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you thought these 
services would be covered. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
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 May 10, 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 ambulance treatment without transport provided 
on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain crown (D2750) for teeth 7 and 8 and intraoral 
periapical first x-ray (D0220) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you fell and broke two of your front teeth, 
which resulted in needing crowns. You also say that you checked that the dental Plan did not cover this service, 
so you went to your family dentist. 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 porcelain crown (D2750) for teeth 7 and 8 and intraoral periapical first x-ray (D0220) provided on 
July 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopic surgical repair of an initial inguinal hernia 
(49650) provided on December 16, 2021. 
 
You asked the Plan to pay for the surgical service. You say that the service should be covered. The Plan denied 
your request. The Plan says Medicare cannot reimburse the Veterans Administration (VA) for care furnished in 
its facilities to veterans and there is no 10-9014 Form and Proof of Member Copayment submitted with the 
claim. 
 
The Plan must follow Medicare rules. The rules say that VA facilities and military hospitals are excluded from 
participating in Medicare. The rules also 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 laparoscopic surgical repair of an 
initial inguinal hernia (49650) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need your occlusal guard replaced 
because your dog chewed it and is unable to be repaired. The Plan denied your request. The Plan says your 
benefit for the occlusal guard 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 occlusal guard was exhausted on date of service October 25, 2023. Therefore, we 
decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99214) provided from April 8, 2023, to 
April 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visits (99214) provided from April 8, 
2023, to April 22, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on August 9, 2023. 
 
You asked the Plan to pay for the maxillary and mandibular complete dentures. You say that you were not able 
to wear the previous dentures after several  trips for adjustments. You also say that you went to another 
provider who successfully made a new set of dentures for you and were unaware that dentures were only 
approved every five years. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service May 4, 2023. Therefore, we 
decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete denture - 
mandibular (D5120) provided on August 9, 2023.