Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve ambulance services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
ambulance services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 17, 
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 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 11, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 17, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on August 16, 2023, 
to August 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy services. You say that the physical therapy services were 
medically necessary. The Plan denied your request. The Plan says the services were not urgent or emergent, nor 
were they approved in advance.  
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 physical therapy services provided on August 
16, 2023, to August 18, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided from August 10, 
2023, to August 13, 2023. 
 
You asked the Plan to pay for the medication. You say that the services should be covered as you disagree with 
the charges. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under 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 pay for self-administered drugs (A9270) 
provided from August 10, 2023, to August 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274) and periodontal maintenance (D4910) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits.  
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 the periodic oral evaluation (D0120), bitewing x-rays (D0274) and periodontal maintenance (D4910) 
provided on July 6, 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 feel the requested services should be pre-
approved. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of x-ray images (D0210) provided on July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits.   
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 the comprehensive oral evaluation (D0150) and complete series of x-ray images (D0210) provided 
on July 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 12, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were informed that 
the coding was wrong and that it was being corrected. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 12, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for an endoscopy dilation provided on  
March 31, 2023. 
 
You asked the Plan to waive the cost sharing for an endoscopy dilation. You say that your Plan has honored 
your other bills as an emergency. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to each in-network Medicare-
covered outpatient surgery at an outpatient hospital facility. The Plan contract also says that you must pay a 
$350 copayment, after your $1,000 Plan deductible, for each in-network Medicare-covered outpatient surgery 
at an outpatient hospital facility. The item or service you asked the Plan to waive the cost sharing for falls within the in-network Medicare-
covered outpatient surgery at an outpatient hospital facility benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to each in-network 
Medicare-covered outpatient surgery at an outpatient hospital facility. This cost sharing is a contractual 
obligation that had not been met at the time an endoscopy dilation was received on March 31, 2023. At the time 
an endoscopy dilation was received, you had $850.72 left towards your $1,000 deductible ($850.72 deductible 
+ $350 copayment = $1,200.72 total responsibility). Therefore, we decided that the Plan does not have to waive 
the cost sharing for an endoscopy dilation provided on March 31, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the leg joint. 
 
You asked the Plan to pre-approve the MRI scan. You say that the MRI is medically necessary. The Plan 
denied your request. The Plan says that the enrollee has not received 6-weeks of provider treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan. Our reviewer says that 
the MRI scan is medically necessary. Our physician reviewer found the enrollee has chronic right knee pain 
due to a stroke and has had extensive conservative therapy. The enrollee qualifies for the requested MRI of the 
right knee. 
 
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 MRI scan have been met. Therefore, we decided that the Plan has to pre-
approve a magnetic resonance imaging (MRI) scan of the leg joint.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus vaccination provided on September 21, 2023.  
 
You asked the Plan to pay for a tetanus vaccination. You say that your physician said you were overdue for a 
tetanus vaccination. The Plan denied your request. The Plan says the services were not related to an illness or 
injury and not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide tetanus vaccination. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to tetanus 
vaccination. Therefore, we decided that the Plan does not have to pay for a tetanus vaccination provided on 
September 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
September 1, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the restaurant called the 
ambulance, but you felt better by the time they arrived. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on September 1, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health partial hospitalization. 
 
You asked the Plan to pre-approve mental health partial hospitalization. You say that your psychiatrist 
requested these additional services to complete your treatment to improve your quality of life and emotional 
health. The Plan denied your request. The Plan says the requested mental health partial hospitalization is not 
medically necessary because the patient can be safely managed on an outpatient basis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve mental health partial hospitalization. 
Our reviewer says that the requested mental health partial hospitalization is not considered medically 
reasonable and necessary in this case. Our physician reviewer found based upon review of the records 
provided, you were not showing any dangerousness to self or others and you have not been exhibiting severe psychological or psychiatric impairment requiring this level of care. You were not showing any perceptual 
disturbance, psychosis or aggressive behaviors. It does not appear medically necessary and reasonable to have 
psychiatric care provided at the partial hospitalization level of care rather than a lower level of care as you did 
not have any suicidal or homicidal thoughts or behavioral disturbance and your symptomatology could be 
treated at a lower level of care. You were not showing any severity of psychological or psychiatric illness. You 
do not meet the criteria for treatment at partial hospitalization level of care and could be treated in a lesser 
restrictive setting as you were not showing any suicidal or homicidal ideation and was not showing any 
psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mental health partial hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve mental health partial hospitalization.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous moderate (conscious) sedation and deep 
sedation/general anesthesia. 
 
You asked the Plan to pre-approve intravenous moderate (conscious) sedation and deep sedation/general 
anesthesia. You say that due to the location of the wisdom tooth, it is too close to your jawbone. Also, there is a 
little pocket of mass that he needs to remove. The Plan denied your request. The Plan says that the enrollee 
requires the removal of multiple teeth or has a medical condition that precludes the use of local anesthesia. 
Therefore, the medical necessity criteria are not met. 
 
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 Plan covers intravenous 
moderate (conscious) sedation and deep sedation/general anesthesia when the services are medically necessary 
and reasonable. 
 
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 intravenous moderate (conscious) 
sedation and deep sedation/general anesthesia. Our reviewer says that the service is medically necessary. Our 
physician reviewer found based on the information included, it is medically reasonable and necessary for 
general anesthesia to be used in the treatment of the enrollee due to the increased risk for fracture of the jaw. 
Since this risk of fracture is possible and documented, if a repair of a potential fracture is needed, it is 
medically reasonable and necessary to perform the procedures under general anesthesia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of intravenous moderate (conscious) sedation and deep sedation/general anesthesia 
have been met. Therefore, we decided that the Plan has to pre-approve intravenous moderate (conscious) 
sedation and deep sedation/general anesthesia.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumococcal vaccine provided on July 31, 2023. 
 You asked the Plan to pay for the vaccine. You say that the services were not related to the enrollee's hospice 
diagnosis. 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 a pneumococcal vaccine provided on July 31, 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 the enrollee has developed a rapport with the 
requested provider. You also say the enrollee has expressed difficulty regarding travel for their medical care. 
The Plan denied your request. The Plan says the enrollee must receive their 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: 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 needs this care to return to prior level of 
function. The Plan denied your request. The Plan says the enrollees medical condition does not require IRF 
services, and care can be provided in another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
prophylaxis (D1110) and periapical first x-ray (D0220) provided on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits.   
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 the problem focused limited oral evaluation (D0140), prophylaxis (D1110) and periapical first x-ray 
(D0220) provided on July 25, 2023.