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

 
We decided that the Plan does not have to pay for ankle foot orthosis (AFO) (L1971) provided on July 5, 2023. 
 
You asked the Plan to pay for the AFO. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
The Plan follows Medicare rules. Medicare rules say that for any durable medical equipment, prosthetics, 
orthotics and supplies (DMEPOS) item to be covered by Medicare, the patient's medical record must contain 
sufficient documentation of the patient's medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). 
 
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 pay for the AFO. Our physician reviewer found that 
there is no documentation of physical signs of arthritic changes to the feet or ankles including painful range of 
motion, crepitus, painful palpation, etc.  Medicare guidelines advise that any durable medical equipment, 
prosthetics, orthotics and supplies item to be covered by Medicare must be supported by documentation.  The 
medical records must contain sufficient documentation of the enrollee's medical condition to substantiate the 
necessity for the type and quantity of items ordered or for the frequency of use or replacement if 
applicable.  The information should include the enrollee's diagnosis and other pertinent information including, 
but not limited to, duration of the enrollees condition, clinical course (worsening or improvement), prognosis, 
nature and extent of functional limitations, other therapeutic interventions and results, past experience with 
related items, etc.  In this particular case the medical documentation does not support any of the above that 
would allow for coverage of the requested ankle foot orthosis.  
 
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 AFO have not been met. Therefore, we decided that the Plan does not have 
to pay for ankle foot orthosis (AFO) (L1971) provided on July 5, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on February 14, 2023, to June 
13, 2023. 
 
You asked the Plan to pay for the psychotherapy. 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 psychotherapy 
provided on February 14, 2023, to June 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) provided on 
July 14, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (ECG). You say that you didnt go to the 
doctors office that day. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for the electrocardiogram (ECG). This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 electrocardiogram (ECG) provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral comprehensive series of radiographic images 
(D0210) provided on August 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new dentist office, and they did not 
get your prior images from the previous dentist office. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for the intraoral comprehensive series of radiographic images (D0210) on March 17, 2021; 
therefore, your benefit for the requested item or service was exhausted on the date of service of March 17, 
2021. Therefore, we decided that the Plan does not have to pay for the intraoral comprehensive series of 
radiographic images (D0210) provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment 
approach. While it is not believed that proton therapy is an experimental therapy, any potential benefit or 
detriment of proton therapy over standard intensity-modulated radiation therapy (IMRT) for routine cases is an investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on June 20, 
2023. 
 
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 the hearing aids in this case 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 only 
covered 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 purchased on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
13, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dental benefit covers one cleaning per year 
and this procedure should be considered a cleaning. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic cushion (E1399). 
 
You asked the Plan to pre-approve the orthopedic cushion. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic cushion (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a pontic (D6241) for tooth #4 and to pay for a retainer 
crown (D6751) for tooth #5 provided on August 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you had a bridge one and you were not 
aware that you were near your benefit maximum. The Plan denied your request. The Plan says your dental 
maximum benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $152 for dental services on June 30, 2023. On July 25, 2023, the Plan paid $1,519 for 
dental services. On August 22, 2023, the Plan paid $1,829 for dental services. For the year of 2023 the Plan 
paid $3,500 ($152 paid + $1,519 paid + $1,829 paid) for dental services; therefore, your dental maximum 
benefit for the year of 2023 was exhausted on the date of service of August 22, 2023. Therefore, we decided 
that the Plan does not have to pay more for a pontic (D6241) for tooth #4 and to pay for a retainer crown 
(D6751) for tooth #5 provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in an average volume assured pressure support (AVAPS) mode which is a 
modality that could be provided by a bilevel positive airway pressure (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; 
records, in fact, document the enrollee was successfully treated with BiPAP in the hospital and weaned to nasal 
canula oxygen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 14, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says your Plan does not cover this service. 
 
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 pay for chiropractic services provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the progressive lenses provided on June 30, 2023. 
 
You asked the Plan to pre-approve the progressive lenses. You say that you are still working, and you need the 
progressive lenses to look at your computer and the paperwork on your desk. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
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 standard eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the progressive lenses are considered upgrades which is 
not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the 
progressive lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
progressive lenses provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed to have routine x-rays completed 
and they were paid for in 2021. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the intraoral radiographic images are not covered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic images (D0220 and D0230) provided on September 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 28, 2022. 
 You asked the Plan to pay for the ED services. You say that you are appealing the Plan's denial of the ER 
services. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on December 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 19, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided 
on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 5, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this 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 November 18, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the rendering provider is the enrollee's primary care 
provider. The Plan denied your request. The Plan says their original decision to deny payment was correct. 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 an office visit provided on June 13, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and the protective restoration (D2940) for tooth #3 provided by an out-of-network 
provider on September 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the amount given back to you is 
unreasonable. 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. 
 
  For the limited oral evaluation (D0140) the total amount billed was $117 and the total allowed amount was $46 
leaving a difference of $71 ($117 billed - $46 allowed). For the intraoral radiographic image (D0220) the total 
amount billed was $44 and the total allowed amount was $14 leaving a difference of $30 ($44 billed - $14 
allowed). For the protective restoration (D2940) the total amount billed was $202 and the total allowed amount 
was $65 leaving a difference of $137 ($202 billed - $65 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 limited oral evaluation (D0140), the 
intraoral radiographic image (D0220), and the protective restoration (D2940) for tooth #3 provided by an out-
of-network provider on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported porcelain/ceramic crown (D6058) provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were given misinformation from the Plan 
regarding your dentist's network status. You say you don't feel you should be responsible to pay out all of this 
money. The Plan denied your request. The Plan says the procedures are not covered under this dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058) provided on July 
12, 2023.