Persius/hicric huggingface dataset:
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 is demonstrating impairments and 
activity limitations that require SNF care. The Plan denied your request. The Plan says the SNF care is not 
medically necessary. 
 
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 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning (D1110) provided by an out-of-network 
provider on March 8, 2023. 
 
You asked the Plan to pay more for the dental service. You say that what the Plan paid was unreasonable and 
you have a $0 copayment for dental. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The total amount the provider billed for the cleaning (D1110) was $151 and the allowed amount was $55 
leaving a difference of $96 ($151 billed - $55 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a cleaning (D1110) provided by an out-of-
network provider on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010), intravenous moderate (conscious) sedation/analgesia  first 15 minutes (D9239), and intravenous 
moderate (conscious) sedation/analgesia - each 15-minute increment (D9243) provided on April 26, 2023. 
 
You asked the Plan to pay for surgical placement of implant body and anesthesia. 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 surgical 
placement of implant body: endosteal implant (D6010), intravenous moderate (conscious) sedation/analgesia  first 15 minutes (D9239), and intravenous moderate (conscious) sedation/analgesia - each 15-minute increment 
(D9243) provided on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory service 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary care office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a primary care office visit . You say that you want to continue seeing this 
provider as your primary care provider (PCP). The Plan denied your request. The Plan says this provider is 
listed as a specialist and not a prime care provider. There are other providers available who are in-network, 
who are within the Medicare allowable distance from your residence. 
 
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 primary care office visit 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 core buildup (D2950) and a porcelain/ceramic crown 
(D2740) provided on May 31, 2023. 
 
You asked the Plan to pay for core buildup (D2950) and a porcelain/ceramic crown (D2740). You say that you 
were in an accident. You also say you feel that you should be covered under your medical. The Plan denied 
your request. The Plan says the denial is upheld as a non-covered benefit. 
 
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 core 
buildup (D2950) and a porcelain/ceramic crown (D2740) provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for a 2D oral image (D0350) provided April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. 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 May 2, 2023. The Plan 
processes claims as they are received; the claim for May 2, 2023 was processed prior to the claim for April 27, 
2023. Therefore, we decided that the Plan does not have to pay for a 2D oral image (D0350) provided April 27, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray provided on April 06, 2023. 
 
You asked the Plan to pay for the knee x-ray. You say that you are requesting reconsideration of the denied 
claim. 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 the knee x-ray provided 
on April 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infiltration of sustained release therapeutic drug (D9613) 
provided on May 23, 2023. 
 
You asked the Plan to pay for D9613. You say that you needed this dental work. The Plan denied your request. 
The Plan says this is not a covered dental benefit. 
 
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 
infiltration of sustained release therapeutic drug (D9613) provided on May 23, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you are struggling with daily tasks and believe that
skilled nursing facility services will help improve your mobility and strength. The Plan denied your request.
The Plan says you do not require skilled nursing services.

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 that you do not have documented skilled nursing or skilled therapy needs. Your care
needs can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of a refractive state (92015) provided from 
May 10, 2023, to May 21, 2023. 
 
You asked the Plan to pay for a determination of a refractive state (92015). You say that the Plan says you owe 
$40 for a determination of refractive state during your annual vision examination. You also say this is incorrect 
because the EOC says that routine (refractive) eye examination is $0 copayment. The Plan denied your request. 
The Plan says the diagnosis you have is not a routine diagnosis. 
 
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 these services when the refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. The Plan rules also say that they cover one routine eye 
refraction every year. The record shows this was a diagnostic refraction and not a routine examination. Based 
on this information, we decided that the Plan's rules for coverage of a determination of a refractive state 
(92015) have not been met. Therefore, we decided that the Plan does not have to pay for a determination of a 
refractive state (92015) provided from May 10, 2023, to May 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on November 18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. 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 the laboratory service 
provided on November 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
28, 2023, to April 30, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not understand 
the 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 a $90 
copayment for emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency room 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 an 
emergency room visit provided on April 28, 2023, to April 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245) provided on March 9, 
2023. 
 
You asked the Plan to pay for the pontic - porcelain/ceramic. You say that you needed the services after having 
a tooth extracted, leaving you no way to chew food on that side of your mouth. The Plan denied your request. 
The Plan says your benefit for the requested services has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 services has been exhausted. The Plan provided evidence of having made 
payments of $1,000 toward the dental services provided in 2023. This includes a partial payment of $778 
towards the pontic - porcelain/ceramic. Therefore, we decided that the Plan does not have to pay for the pontic 
- porcelain/ceramic (D6245) provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on April 
10, 2023. 
 
You asked the Plan to pay for D0431. You say that this dental work should be covered. The Plan denied your 
request. The Plan says D0431 is not covered. 
 
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 
adjunctive pre-diagnostic test (D0431) provided on April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
compression stockings are a not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors. 
 
You asked the Plan to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electronic connections are only covered for 
certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollees bilateral upper limb 
strength and function are adequate for the enrollee to be able to control the power options using their own 
switches which are included in the allowance of the power options. Based on this information, we decided that 
Medicare rules for coverage of electronic connection between wheelchair controller and two or more power 
seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve 
electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of extracranial arteries, and 
the new patient office visit provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for the duplex scan, and the office visit. You say that you have had 
these same services for several years. 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 $80 
copayment for other Medicare-covered radiological diagnostic services, performed in a physicians office or at 
a free-standing facility (such as a radiology center or medical clinic), and a $15 copayment for services from a 
specialist or under certain circumstances, treatment by a nurse practitioner, physicians assistant, or other non-
physician health care professional in a specialists office. 
 
You have been asked to pay a $80 copayment for the duplex scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $15 
copayment for the office visit. This item/service falls within the physician/practitioner services, including 
doctors office visits 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 the duplex scan of 
extracranial arteries, and the new patient office visit provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported porcelain/ceramic crown tooth #13 
(D6065) provided on April 28, 2023. 
 
You asked the Plan to pay for the implant supported porcelain/ceramic crown. You say that you do not agree 
with the denial of the dental service. The Plan denied your request. The Plan says this is not a covered service 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an implant 
supported porcelain/ceramic crown tooth #13 (D6065) provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote device evaluation provided on April 04, 2023. 
 
You asked the Plan to pay for the remote device evaluation. You say that prior authorization is not needed for 
this service. 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 the remote device 
evaluation provided on April 04, 2023.