Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 24, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on March 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 17, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on January 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy evaluation to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy evaluation. You say that you do not agree with the denial 
of the requested service. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
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 
physical therapy evaluation to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdomen.  
 
You asked the Plan to pre-approve the CTA of the abdomen. You say that the services are medically necessary.  
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA of the abdomen. Our reviewer 
says that the CTA scan is not medically necessary. Our physician reviewer found the enrollee has no evidence 
of an abdominal aneurysm on abdominal ultrasound. The clinical guidelines for the use of an abdominal CTA 
have not been met based on review of the submitted clinical documentation. At this time an abdominal CTA 
would not be considered medically reasonable and necessary in this enrollee's clinical management. 
 
 
 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 CTA of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you are temporarily staying with your 
sister and need to be able to get to your follow-up appointments.  
 You also say that the doctor's office is outside the transportation benefit mileage range.  The Plan denied your 
request. The Plan says the exception to exceed the 50 mile limit per one way trip under the supplemental 
transportation exceeds the benefit limit. 
 
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 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 miles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for  the eye injections provided from January 
20, 2023, to February 17, 2023. 
 
You asked the Plan to waive the copayments for  the eye injections. You say that you believe you were double 
billed. You say you should not have to pay for an outpatient copayment when the services can be done in an 
office for less money. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
 You have been asked to pay a $295 copayment for the eye injections on each date of service. The eye injections 
fall within outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical center benefit category. The record shows the claims were billed with place of service code, 22, which 
is an outpatient hospital. 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 copayments for  the eye injections provided 
from January 20, 2023, to February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on January 16, 2023. 
 
You asked the Plan to pay for limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 limited 
oral evaluation  problem focused (D0140) provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma. 
 
You asked the Plan to pre-approve a platelet rich plasma. The Plan denied your request. The Plan says a 
platelet rich plasma is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. The record shows the injection was requested to treat a joint 
condition. Based on this information, we decided that Medicare rules for coverage of a platelet rich plasma 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) 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 record indicates that the requested 
root canal was incomplete. Therefore, we decided that the Plan does not have to pay for incomplete endodontic 
therapy (D3332) provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for second stage implant surgery (D6011 x2) provided on April 
10, 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 second 
stage implant surgery (D6011 x2) provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional hours for in-home support services. 
 
You asked the Plan to pre-approve 60 additional hours for in-home support services. You say that you had to 
use up all of your 120 hours for the year. You also say that you are now requesting additional hours to help you 
with in-home support services. The Plan denied your request. The Plan says it has been confirmed that you 
have used 120 hours between January 5, 2023, and May 11, 2023. The Plan also says that you are no longer 
eligible, and no additional hours will be covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered. However, the Plan offers a custodial care/in-home support 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at the file and Medicare rules. Though the Plan offers a custodial care/in-home support benefit in 
excess of Medicare coverage, this benefit is limited to 120 hours per year. The case file shows that the Plan has 
already paid for 120 hours of in-home support services provided in the 2023 calendar year. This means that 
your benefit for in-home support services is exhausted. Based on this information, we decided that Medicare 
rules for coverage of in-home support services have not been met. Specifically, we find that the services at 
issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-
approve 60 additional hours for in-home support services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed bridge (D6242, D6752 x 2) provided on March 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were misled because you were told these 
were covered benefits. The Plan denied your request. The Plan says these services are not covered under the 
Plan's 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 the fixed 
bridge (D6242, D6752 x 2) provided on March 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 01, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on March 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) of the abdomen. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary as the 
enrollee is down around 15 pounds. The Plan denied your request. The Plan says the records don't show that 
any standard testing has been done. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is 93 years old and has had an 8-
pound weight loss in past 6 months. The enrollee has had no other imaging tests. At a weight of 119 pounds, 
the enrollee would be a good candidate for an ultrasound examination and such studies have not been done.  
The medical necessity of CT of the abdomen has not been established in the provided records. 
 
 
 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) of the abdomen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 6, 2023 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that since you 
were not transported in the ambulance, you dont think you should have to pay the full amount for the 
ambulance services that you did not use. The Plan denied your request. The Plan says these services are 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 April 6, 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 with no 
transport provided on April 6, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (L1971) provided on February 27, 
2023. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you are requesting reconsideration of the 
claim submitting medical records to finish processing the claim.  The Plan denied your request. The Plan says 
the invoice did not include the carriers tracking number or a shipping date. 
 
The Plan must follow Medicare rules. Medicare rules say that the delivery services package identification 
number, supplier invoice number, or alternative method that links the suppliers delivery documents with the 
delivery services records. We looked at the file and Medicare rules. The invoice did not include the carriers 
tracking number or shipping date. Based on this information, we decided that Medicare rules for coverage of 
the ankle foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an ankle 
foot orthosis (L1971) provided on February 27, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography; of the larynx (95865) and the 
nonparaspinal muscle test (95870) provided on November 22, 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 that the services provided were not medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services provided are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the generally accepted standard of care at the present time is for patients to be monitored during a 
thyroidectomy. Current literature has shown that said monitoring is useful in avoiding recurrent laryngeal nerve 
injury. It can also be of use enabling the surgeon to diagnose recurrent laryngeal nerve injury intraoperatively 
to estimate the postoperative nerve function and to modify the surgical strategy to avoid bilateral vocal cord 
paralysis. In as much, it can be said that based on current literature these services provided were consistent with 
standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for  
the needle electromyography; of the larynx (95865) and the nonparaspinal muscle test (95870) provided on 
November 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on April 3, 2023. 
 
You asked the Plan to pay for the prophylaxis - adult and periodic oral evaluation. You say that you have been 
receiving care from this provider for the past 35 years and have a great deal of trust in their competency and 
ability to provide excellent service. 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 a prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided on 
April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on February 14, 
2023. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you were told there would be a 
$0 copayment. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for diabetic supplies. This item/service falls within the durable 
medical equipment (DME) and related 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 $24.05 ($120.24 allowed amount x 20% = 
$24.05). Therefore, we decided that the Plan does not have to waive the coinsurance for diabetic supplies 
provided on February 14, 2023.