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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to medical appointments. The Plan denied your request. The Plan says this request will exceed the maximum 
number of transportation trips allowed per year. 
 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 72 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 trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost Glucose Control. 
 
You asked the Plan to pre-approve Boost Glucose Control. You say that the enrollee requires this supplement 
for maintenance of their wight and strength status. The Plan denied your request. The Plan says the 
documentation provided does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them.  Therefore, we decided that the Plan 
does not have to pre-approve Boost Glucose Control.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the end-stage renal disease (ESRD) related services to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the end-stage renal disease (ESRD) related services. You say that you have 
already secured affordable and reliable transportation for these services. 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 
the end-stage renal disease (ESRD) related services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport and 
ground mileage provided on October 22,  2022. 
 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage provided. You say that the worker compensation case is closed, and claims should be paying. The Plan 
denied your request. The Plan says that this is not a covered service 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer.  
Therefore, we decided that the Plan has to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on October 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 D1330, D0220, D0230, D0274 and does not have to waive 
the copayment for D7210 provided on February 24, 2022, to October 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay anymore for the 
services you received, because you already paid the provider. 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. This benefit includes the 
requested intraoral - periapical first radiographic image and intraoral - periapical each additional radiographic 
image but are limited to one every three years and bitewings - four radiographic images but is limited to one 
every year. Oral hygiene instructions (D1330) is not covered under the Plans dental benefits. The Plan contract 
says that enrollees must pay 40% coinsurance for oral surgery (surgical removal of erupted tooth). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1330 is not among 
those covered under this benefit under any circumstance.  
 
The allowed amount for D7210 is $175.21, resulting in a coinsurance amount of $70.08 ($175.21 x 40% = 
$70.08), and a Plan payment of $105.13. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered D0220, D0230 
and D0274 on February 24, 2022. Therefore, these benefits were exhausted as of September 20, 2022.   
 
Therefore, we decided that the Plan does not have to pay for oral hygiene instructions (D1330), intraoral - 
periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), 
bitewings - four radiographic images (D0274) and does not have to waive the copayment for extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210) provided on February 24, 2022, to October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve massage therapy with an out-of-network provider. You say that you want to 
see this provider. These services should be approved with this provider as they were in 2022. The Plan denied 
your request. The Plan says this provider is no longer in-network. These services can be provided by in-
network providers. 
 
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 
massage therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the cataract surgeries provided on April 20, 
022, and May 4, 2022. 
 
You asked the Plan to reduce the cost share for the cataract surgeries. You say that this provider is in-network. 
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 out-of-network outpatient surgery. 
Your contract with the Plan also says that you must pay 40% coinsurance after meeting the deductible for out-
of-network outpatient surgery. 
 
The records show the claims were processed as out-of-network. You have been asked to pay $634.56 towards 
the deductible for the cataract surgery provided on April 20, 2022. The item or service you asked the Plan to reduce the cost share for falls within the outpatient surgery benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-network 
outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the cataract 
surgery was received on April 20, 2022.  
 
You have also been asked to pay up to 40% coinsurance for each cataract surgery. 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 reduce the cost share for the cataract surgeries provided on April 20, 022, and May 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 11, 2023. A comparison of the claims shows the claim lines are duplicates. There is no evidence presented to support that the billed services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for coverage have not been met.  Therefore, we decided 
that the Plan does not have to pay for procedure code 99285 billed for date of service November 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at a high risk for falls and head injury 
and is not getting necessary level of care at home.  The Plan denied your request. The Plan says admission to an 
IRF is not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehab goals and medical 
complications that cannot be sufficiently met at a lower level of care. The Plan denied your request. The Plan 
says  an IRF admission is not medically necessary, and the enrollee's needs can be met at an alternate level of 
care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx urinary tract infection (UTI) panel coded as 
87481, 87500, 87641, 87653, 87798, 87801 provided on January 30, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the laboratory service. You say that the enrollee was referred to your testing lab 
by the doctor. This referral was based on the medical necessity of the enrollee. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered.  
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 Altru Dx urinary tract infection (UTI) panel 
coded as 87481, 87500, 87641, 87653, 87798, 87801 provided on January 30, 2023, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the impact-resistant lenses polycarbonate and the anti-
reflective coating provided on January 24, 2023. 
 
You asked the Plan to pay for the impact-resistant lenses polycarbonate and the anti-reflective coating. You say 
that you do not have any extra money to spend on your first ever reading glasses. The Plan denied your request. 
The Plan says the items are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers basic lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered upgrades and are not 
covered services. Based on this information, we decided that the Plan's rules for coverage of the impact-
resistant lenses polycarbonate and the anti-reflective coating have not been met. Therefore, we decided that the 
Plan does not have to pay for the impact-resistant lenses polycarbonate and the anti-reflective coating provided 
on January 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 105 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would have chosen a different option you 
had been made aware prior. The Plan denied your request. The Plan says your benefit for the requested service 
$2,500 dollar limit was 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service February 7, 2022. Therefore, we 
decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete denture - 
mandibular (D5120) provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced hip feature (codes 
L5331, L5626, L5631, L5649, L5650, L5671, L5673, L5683, L5707, L5828, L5845, L5848, L5850, L5856, 
L5920, L5925, L5960, L5981, and L5999) to be rendered by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a prosthetic leg with advanced hip feature. You say that the requested OON 
provider specializes in the type of prosthetic you need for the type of hip disarticulation amputation of your hip. 
You also say that other providers in-network are not able to provide the same care and or ability to provider a 
prosthetic that would fit and work as well as the prosthetics you need. The Plan denied your request. The Plan 
says the requested OON provider is not contracted in the Plans network. The Plan also says there are no 
extenuating circumstances related to geographic access, compelling continuity of care making it medically 
necessary that future care come only from this requested provider, or unique medically recognized 
qualifications of the requested OON provider to justify prior authorization of OON benefits.  
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 prosthetic leg with advanced hip feature (codes L5331, L5626, L5631, L5649, L5650, L5671, L5673, L5683, 
L5707, L5828, L5845, L5848, L5850, L5856, L5920, L5925, L5960, L5981, and L5999) to be rendered by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone, and the family feels 
rehabilitation/skilled nursing care for a short while is needed to be able to return home alone.  The Plan denied 
your request. The Plan says no skilled nursing needs are identified. Services needed may be provided safely in 
a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.