Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions and bone replacement grafts (D7953, 
D7140) provided on February 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 February 20, 2023. 
Therefore, we decided that the Plan does not have to pay more for extractions and bone replacement grafts 
(D7953, D7140) provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided medical records 
document the need for a bilevel positive airway pressure (BiPAP) device yet a Trilogy non-invasive ventilator 
is being requested. Provided records do not document trial and failure of a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and panoramic radiographic 
images (D0150, D0330) provided on February 13, 2023, to February 14, 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 October 31, 2022 
(D0150) and May 24, 2021 (D0330). Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation and panoramic radiographic images (D0150, D0330) provided on February 13, 
2023, to February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction and limited oral evaluation (D0140, 
D7210) provided on August 17, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The limited oral evaluation denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment.  The limited oral evaluation denied correctly as they do not fall within your dental benefits. 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 an extraction and limited oral evaluation (D0140, D7210) provided on 
August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you cannot walk or stand longer 
than a minute. The Plan denied your request. The Plan says that there is no documentation of a face-to-face 
evaluation being performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a face-to-face evaluation must be conducted, and 
it needs to include the necessary information listed in the Medicare rules section. 
 
We looked at the file and Medicare rules. The record does not show documentation that a face-to-face 
evaluation has been performed to address your mobility limitations. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-rays, and cleaning 
(D1110, D0274, D0120) provided on February 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 
 The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation, bitewing x-rays, and cleaning (D1110, D0274, D0120) provided on 
February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
performed by a provider other than your primary care physician provided on March 08, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan performed by a provider 
other than your primary care physician. You say that you disagree with the copayment applied. 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 $120 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $120 copayment for a computed tomography (CT) scan performed by a provider 
other than your primary care physician. This item/service falls within the outpatient diagnostic test 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 computed tomography (CT) scan performed 
by a provider other than your primary care physician provided on March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee urgently needs this device 
and procedure due to her worsening heart failure. The Plan denied your request. The Plan says the 
CardioMEMS device has been determined to be of uncertain value in the most recent guidelines and carries a 
risk of significant complications including death and severe pulmonary artery injury. The CardioMEMS device 
at this point should only be approved for enrollees enrolled in a clinical trial. There is no indication that this 
enrollee is enrolled in a clinical trial of the device. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) 
in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary 
artery pressure in the management of enrollees with congestive heart failure. The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in enrollees in whom 
the CardioMEMS system was implanted, reflecting an enrollee population with preserved ejection fraction and 
was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in enrollee management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this device due to 
medical necessity. The enrollee is at risk of dying if she does not get this ventilator. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show that the ordered settings 
for the noninvasive ventilator can be delivered by a bi-level positive airway pressure (BiPAP) machine with 
average volume assured pressure support (AVAPS) capability. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode which is a modality which could be provided by a BiPAP device with AVAPS and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee suffers from chronic respiratory 
failure consequent to COPD. The enrollee's condition is life-threatening and would put him at a heightened risk 
of serious harm or morbidity if he does not use a non-invasive ventilator. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested device. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode which is a modality which could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 15, 2022, to August 22, 
2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on August 15, 2022, to August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the computed tomography (CT) scan of the 
cervical spine without contrast material (72125), office visits (99203, 99211), 3D rendering with interpretation 
and reporting of computed tomography, requiring image post processing (76377), and the chiropractic 
manipulative treatments (98940) provided from August 10, 2022, through December 14, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not payable as they were rendered by an out-of-network provider.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract says that chiropractic services are 
not covered when rendered by an out-of-network provider.  
  
 
 
The record shows that the services at issue were rendered by an out-of-network chiropractor. The Plan contract 
states that chiropractic services are not covered when rendered by an out-of-network provider. Additionally, the 
only covered chiropractic service is manual manipulation of the spine to correct a subluxation. Therefore, we 
decided that the Plan does not have to issue reimbursement for the computed tomography (CT) scan of the 
cervical spine without contrast material (72125), office visits (99203, 99211), 3D rendering with interpretation 
and reporting of computed tomography, requiring image post processing (76377), and the chiropractic 
manipulative treatments (98940) provided from August 10, 2022, through December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination provided on February 6, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye examination. You say that the provider performing services in a 
nursing home facility is not responsible for obtaining authorization. The Plan denied your request. The Plan 
says the provider is out-of-network and there was no prior authorization. 
 
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 did not pre-approve the 
medical eye examination. We found no exception that would require the Plan to pay for the medical eye 
examination. Therefore, we decided that the Plan does not have to pay for the medical eye examination 
provided on February 6, 2023, by an out-of-network (OON) provider.
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 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had a 
low sugar episode, the first ever. You also say that you became okay and refused to be taken to the emergency 
room. 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 23, 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 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99202) provided on  
March 8, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to issue reimbursement for the office visit (99202) provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 9, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. There is no network deficiency for these services and alternate 
network providers were found. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
August 9, 2022. 
 
You asked the Plan to issue reimbursement 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 purchased from 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 purchased from the Plans select hearing aid provider.  
 
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 covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on August 9, 2022.