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

We decided that the Plan does not have to pre-approve continued coverage for a home ventilator, any type, used with non-invasive interface (E0466).

You asked the Plan to pre-approve a ventilator. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says the request for continued use of a device to assist with breathing (noninvasive ventilator or NIV) coded as E0466 does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. The provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this policy will be denied as not reasonable and necessary. The provided records also do not document compliant use of the device. The enrollee only used the device for 7 days out of 90 with an average use of 3.8 hours on those 7 days.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage for a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft (D6104 x1). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have been approved for bone graft (D6104 x2) so the third one is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve bone graft (D6104 x1).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 3, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice on this 
date. 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 ambulance services provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an insertion of non-tunneled central venous tube for infusion, 
an electrocardiogram and critical care provided on February 7, 2023.  
You asked the Plan to pay for an insertion of non-tunneled central venous tube for infusion, an 
electrocardiogram and critical care. You say that the claim should be reprocessed. 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 an insertion of non-tunneled central venous tube for infusion, 
an electrocardiogram and critical care provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (including elevation of a full thickness 
flap and closure)one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), bone 
replacement graftretained natural toothfirst site in quadrant (D4263), bone replacement graftretained natural 
tootheach additional site in quadrant (D4264), and the guided tissue regeneration-resorbable barrier, per site 
(D4266 x 2) provided on November 9, 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 these services are 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous 
surgery (including elevation of a full thickness flap and closure)one to three contiguous teeth or tooth 
bounded spaces per quadrant (D4261), bone replacement graftretained natural toothfirst site in quadrant 
(D4263), bone replacement graftretained natural tootheach additional site in quadrant (D4264), and the 
guided tissue regeneration-resorbable barrier, per site (D4266 x 2) provided on November 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan provided on 
November 02, 2022. 
 
You asked the Plan to pay for a magnetic resonance imaging (MRI) scan. You say that this was medically 
necessary and should be 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 a magnetic resonance 
imaging (MRI) scan provided on November 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air filters (A7038), purchased on December 27, 2022. 
 
You asked the Plan to pay for the air filters. You say that the member needs the items. The Plan denied your 
request. The Plan says the maximum allowed for this item has already been purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that 2 air filters are allowed a month. Quantities 
greater than 2 air filters a month will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air filters have not been met. Specifically, the documentation submitted indicated the enrollee 
already purchased the maximum amount of air filters. Therefore, we decided that the Plan does not have to pay 
for the air filters (A7038), purchased on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 9, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that the eye refraction was necessary to make sure 
nothing further was going on with your eyes before issuing a new prescription for glasses. The Plan denied 
your request. The Plan says refraction is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed during a routine vision exam. 
 
 
 
 
 We looked at the file and the Plan's rules. The Plan contract clearly states that eye refractions performed in 
conjunction with Medicare-covered eye exams are not covered. Specifically, you stated that the refraction was 
necessary for the provider to issue a new prescription for glasses. Based on this information, we decided that 
the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does 
not have to pay for the eye refraction (92015) provided on January 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
24, 2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen by two different providers.  
The Plan denied your request. The Plan says the service is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the enrollee received two evaluation and management services 
on the same date. The services were provided by two different physicians in the same specialty and in the same 
medical group. If more than one evaluation and management service is provided on the same day to the same 
patient by more than one physician in the same specialty in the same group, only one evaluation and 
management service may be reported. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99285 billed for date of service September 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological examinations (73502, 73560, 73610) 
provided on October 7, 2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the radiological examinations. You say that the services were medically 
necessary. The Plan denied your request. The Plan says services rendered with out-of-network providers are 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 requested 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 radiological examinations (73502, 73560, 
73610) provided on October 7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 20, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for an office visit. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an office visit provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided on September 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should not be responsible for the 
difference as the provider did not tell you they were out-of-network. 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. 
 
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 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 endodontic therapy, molar tooth (excluding 
final restoration) (D3330) provided on September 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says 8 additional physical therapy 
visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you have a chronic back condition and an established 
home exercise program. You have not changed function materially and are able to continue with a home 
program. Therefore, continued input from a skilled therapist is not medically 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient observation provided on November 17, 2022. 
 
You asked the Plan to pay for an outpatient observation. You say that this was medically necessary and should 
be 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 an outpatient 
observation provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing 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 July 12, 2021. Therefore, 
we decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on February 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had no type of exam. You also say that your 
prior dentist sent the x-rays and the information for the extraction of one tooth. 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 comprehensive oral evaluation - new or established patient was exhausted on date of 
service January 26, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation - new or established patient (D0150) provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), core buildup, 
including any pins when required (D2950), localized deliveries of antimicrobial agents (D4381 x14), four 
gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630 x2) 
provided on January 3, 2023.  
You asked the Plan to pay for the adjunctive pre-diagnostic test, core buildup, localized deliveries of 
antimicrobial agents, gingival irrigations, and drugs or medicaments. You say that you felt because this was 
necessary care you required that more expense would be covered under your plan. The Plan denied your 
request. The Plan says these services are not covered expenses 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431), core buildup, including any pins when required (D2950), localized 
deliveries of antimicrobial agents (D4381 x14), four gingival irrigations (D4921 x4), and drugs or medicaments 
dispensed in the office for home use (D9630 x2) provided on January 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
December 21, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for an emergency care visit. This item/service falls within the 
Emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency care 
visit provided on December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient stay provided on October 05, 
2022, to October 06, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you are disputing the share cost. 
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 inpatient hospital care. 
 
You have been asked to pay a $200 copayment for inpatient stay. This item/service falls within the inpatient 
hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient stay provided on 
October 05, 2022, to October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatrist visit provided on January 03, 2023. 
 
You asked the Plan to pay for a podiatrist visit. You say that this was medically necessary and should be 
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 a podiatrist visit 
provided on January 03, 2023.