Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 You asked the Plan to pre-approve the therapy services. You say that 10 additional visits of physical therapy 
are reasonable and necessary. The Plan denied your request. The Plan says 10 additional visits of physical 
therapy are not reasonable and 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 the therapy services. 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 the enrollee has been receiving occupational therapy since July 10, 
2023, and continues to experience hip pain and tenderness, but motor strength and range of motion are 
essentially normal. The enrollee is performing strengthening and range of motion exercises that can be 
accomplished with a home exercise program and functional progress has plateaued.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on June 14, 
2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. You say that these services were 
medically necessary. 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 home visit, and 
debridement of nails provided on June 14, 2023.
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 June 5, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you were not aware that the office visit 
would not be covered. The Plan denied your request. The Plan says this chiropractic service is excluded from 
coverage. 
 
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 June 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the CT scan; abdomen provided on June 21, 
2023. 
 
You asked the Plan to waive the cost share for the CT scan; abdomen. You say that you feel you should not 
have to pay for this CT scan because they scanned the wrong part of your body. 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 after the deductible is met for each advanced imaging service (e.g., magnetic resonance imaging 
(MRI), CT and positron emission tomography (PET) scans, nuclear medicine, and stress tests). The Plan 
contract also says that there is a $750 deductible which applies to certain items and services. 
 
You have been asked to pay a total of $89.67 for the CT scan; abdomen. You have been asked to pay $49.74, 
which is less than the standard $200 copayment. You also had not met your $750 deductible at the time of the 
CT scan. The Plan applied $39.93 toward your deductible to meet the $750 deductible ($49.74 + $39.93 = 
$89.67). This item/service falls within the outpatient hospital services 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 cost share for the CT scan; abdomen provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported porcelain/ceramic crown (D6058) and 
re-cement or re-bond implant/abutment supported crown (D6092) provided on May 1, 2023. 
 
You asked the Plan to pay for abutment supported porcelain/ceramic crown (D6058) and re-cement or re-bond 
implant/abutment supported crown (D6092). You say that you would like to appeal the process of denial. The 
Plan denied your request. The Plan says these services 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 Plan's 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 abutment 
supported porcelain/ceramic crown (D6058) and re-cement or re-bond implant/abutment supported crown 
(D6092) provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 18, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you thought the maintenance was covered and 
would like to be reimbursed. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the periodontal maintenance is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000). 
 
You asked the Plan to pay for foot orthotics. You say that the medical records support the medical necessity for 
the foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride  excluding varnish (D1208), 
and prophylaxis - adult (D1110) provided on September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you already paid the provider and are asking for 
reimbursement. You also say that you have been going to this office for a while and did not realize this was a 
new provider to the office. 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 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 
topical application of fluoride  excluding varnish (D1208), and prophylaxis - adult (D1110) provided on 
September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you asked the new dentist to fix your old 
dentures, but they made a new pair, and they never mentioned you had to wait 5 years to get new dentures. The 
Plan denied your request. The Plan says your benefit for the requested items or 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 the Plan paid for a complete upper denture (D5110) and a complete lower denture (D5120) on March 10, 
2020; therefore, your benefit for the requested items or services was exhausted on the date of service of March 
10, 2020. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a 
complete lower denture (D5120) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on January 5, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2013, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for 
OTC items provided on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. 
 
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that the enrollee declined to use the 
preferred test strips, as he has another type of meter. The Plan denied your request. The Plan says the provider 
did not indicate that there was a reason the enrollee could not use the preferred diabetic testing supplies, One 
Touch, and therefore your request was not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage to certain brands of 
products and that the plan only covers OneTouch line by LifeScan. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Lite test strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve FreeStyle Lite test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied crown because 
it was denied. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a crown (D2750) for tooth #20 on September 21, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of September 21, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a crown (D2740) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infiltration of sustained release therapeutic drug, per 
quadrant (D9613). 
 
You asked the Plan to pre-approve the infiltration of sustained release therapeutic drug. You say that your tooth 
is sore and tender. The Plan denied your request. The Plan says this service is not covered under your benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve infiltration 
of sustained release therapeutic drug, per quadrant (D9613).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice or home health care provided in patient's home 
provided by an out-of-network provider from April 1, 2021, to April 30, 2021. 
 
You asked the Plan to pay for the hospice or home health care services. You say that the claims have been 
corrected several times and you spoke to the Plan in August of 2022 to have the claims reprocessed. The Plan 
denied your request. The Plan says more than one calendar year from the date of service had passed before the 
claim was filed. 
 
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 the hospice or home health care services was not filed until April 6, 2023. 
This means that more than 1 calendar year from the date of service had passed before a claim was filed. Also, 
the automated remittance advice documentation has a date of May 12, 2021, which also 1 calendar year has 
passed since the automated remittance documentation. Therefore, we decided that the Plan does not have to pay 
for hospice or home health care provided in patient's home provided by an out-of-network provider from April 
1, 2021, to April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on February 28, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2013, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on April 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips as you have 
multiple doctor and therapy appointments to attend. The Plan denied your request. The Plan says you have used 
your 24 one-way transportation trips and the benefit has been exhausted. 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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional trips for your doctor and therapy 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 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
May 26, 2023, by an OON provider.  
 
You asked the Plan to pay for OON chiropractic services. You say that you are in pain and get some relief from 
chiropractic services. The Plan denied your request. The Plan says services obtained from 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 chiropractic manipulative treatment (98941) 
provided on May 26, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on January 5, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks, and you used the information you had from the 2022 form. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2023, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient hospital stay 
provided from May 8, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient hospital stay. You say that you 
were transferred between two different hospitals, you should not have to pay this large amount per admission. 
There's no way you can pay these copayments. 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 $400 
copayment per day for days 1-4 for inpatient hospital care.  
 
You were in the hospital for 4 days, resulting in a $1,600 total copayment (4 days x $400 = $1,600). You have been asked to pay a $1,600 total copayment for an in-network acute inpatient hospital 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 an in-network acute inpatient hospital stay provided from May 8, 2023, to May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the first set of dentures could not be made to fit, 
and the enrollee needed a second set of dentures made. The Plan denied your request. The Plan says the 
enrollees benefit for the requested items or 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 the Plan paid for a complete upper denture (D5110) and a complete lower denture (D5120) on 
November 20, 2019; therefore, the enrollees benefit for the requested items or services was exhausted on the 
date of service of November 20, 2019. Therefore, we decided that the Plan does not have to pay for a complete 
upper denture (D5110) and a complete lower denture (D5120) provided on December 22, 2022.