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

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there are no medical indications for 
an Implantable Loop Recorder (ILR) in the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene analysis (81240). 
 
You asked the Plan to pre-approve F2 gene analysis (81240). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that genetic testing of the F2 genes was requested. We looked at the file, and Medicare rules. 
This testing is not covered except for those who are pregnant. Based on this information, we decided that 
Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve F2 gene analysis (81240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported porcelain/ceramic crown (D6058) 
provided on April 4, 2023. 
 
You asked the Plan to pay for the abutment supported porcelain/ceramic crown. You say that the plans website 
states implants and crowns are covered services. The Plan denied your request. The Plan says procedure code 
D6058 is not listed as covered benefits under your supplemental 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 an 
abutment supported porcelain/ceramic crown (D6058) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5140) provided on January 18, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not payable as they were rendered by 
an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plans select hearing aid vendor.  
 
 
  
 
 
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when provided by the Plans select hearing aid vendor. However, the hearing aids in this case were 
rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
hearing aids (V5140) provided on January 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says the 
requested transportation exceeds your mileage 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 routine transportation when each one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a resin-based composite - four or more 
surfaces or involving incisal angle (anterior) (D2335) provided on March 1, 2023. 
 
You asked the Plan to waive the copayment for the resin-based composite. You say that the provider indicated 
that you would only owe a $50.00 copayment for services. 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 $25 
copayment per tooth for resin-based composite (white) - anterior (front) or posterior (back) when provided in-
network. 
 You have been asked to pay a $25 copayment for the resin-based composite. This service falls within the 
comprehensive 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 copayment for a resin-
based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on March 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided on April 26, 2023. 
 
You asked the Plan to pay for the pulp vitality tests. You say that the test was performed to see if a root canal 
procedure was needed. You also ask if is there another code that should have been used by the provider. The 
Plan denied your request. The Plan says this procedure is not covered 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 pulp 
vitality tests (D0460) provided on April 26, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you have tried and failed non-surgical 
methods and you are appealing this denial. The Plan denied your request. The Plan says you must receive your 
care from a 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 to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0329) and miscellaneous 
durable medical equipment (E1399). 
 
You asked the Plan to pre-approve a hospital bed and accessories. You say that the enrollee needs a fully 
electric, not manual, reclining bed to assist with breathing. The enrollee needs a fully electric bed to prevent 
snoring and bed sores. The Plan denied your request. The Plan says a total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0329) and miscellaneous durable medical equipment (E1399).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit and does not have to pay for 
the self-administered drugs provided on Mach 4, 2023. 
 
You asked the Plan to waive the copayment for the ER visit and to pay for the self-administered drugs. You say 
that this claim was denied, and the Plan should have paid something. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. The Plan also says that the medication is not covered as a medical 
benefit under the Plan. 
 
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 an in-network emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER 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.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit 
and does not have to pay for the self-administered drugs provided on Mach 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in urgent need of a transfer to an acute 
rehabilitation hospital. You say it is the physician's conclusion that the enrollee is appropriate for that level of 
care. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not been 
met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the Plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 medically necessary. Our physician reviewer found despite a benign chest x-ray, a patient with 
clinical hemoptysis requires a CT of the chest for evaluation. A plain chest x-ray is a very insensitive tool for 
evaluation of a patient with hemoptysis and CT scanning is the exam of choice in such a patient. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the thorax.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
an ambulance because your heart rate was high, and you expected to be transferred to the emergency room. 
You also say that the ambulance crew worked to bring your heart rate down to a more manageable level, 
thereby saving the hospital time and money. 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 February 17, 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 February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee-ankle-foot orthosis to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a knee-ankle-foot orthosis to be provided by an OON provider. You say that 
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
providers available to the enrollee that can provide the knee-ankle-foot orthotic being requested. 
 
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 knee-ankle-foot orthosis 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 pre-approve an abutment supported porcelain fused to metal crowns 
(noble metal) for teeth number 18 and 19 (D6061 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment 
supported porcelain fused to metal crowns (noble metal) for teeth number 18 and 19 (D6061 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5226) provided on March 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that you told the previous provider to keep the old 
dentures because they did not fix them, and they do not have any record of you bringing them back. 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 partial lower denture (D5211) on December 24, 2019; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 24, 2019. Therefore, we decided 
that the Plan does not have to pay for a partial lower denture (D5226) provided on March 6, 2023.  Your complaint about the provider not properly documenting the dental services is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care services provided from December 11, 
2022, to January 21, 2023. 
 
You asked the Plan to pay for custodial care. You say that your daughter lives in a different state and cannot 
stay for long periods of time. The Plan denied your request. The Plan says that custodial care is not covered by 
Medicare. 
 
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. The rules also say that no provider or supplier shall receive 
payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the 
Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. The records also 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 custodial care services 
provided from December 11, 2022, to January 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee does have severe chronic obstructive pulmonary disease (COPD) with chronic respiratory failure and at this time a bilevel positive 
airway pressure (BiPAP) with a backup rate and average volume assured pressure support (AVAPS) would be 
an appropriate therapy option to treat the disease progression. There is no data or recent studies to suggest a 
trilogy ventilator with set tidal volumes is superior. 
 
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 a ventilator (E0466).