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

 
We decided that the Plan does not have to pre-approve non-emergency transportation: wheelchair van (A0130).  
 
You asked the Plan to pre-approve non-emergency transportation: wheelchair van (A0130). You say that you 
feel this should be covered. The Plan denied your request. The Plan says they may cover non-emergency 
transportation only upon discharge from a hospital to a skilled nursing facility. The Plan also says that based on 
the information we received, you do not require ambulance transportation. The Plan also says that you are not 
being discharged from a hospital to a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation: wheelchair van (A0130).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 21, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating that the 
services were medically necessary and you have submitted medical documentation to support. 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 lab testing provided on 
June 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you did not 
receive proper care and do not feel you should be responsible for 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 
(ER) visit provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that your dental bridge broke and you need a 
new bridge. 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 a partial upper denture (D5225) on April 20, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 20, 2021. Therefore, we decided that 
the Plan does not have to pre-approve a partial upper denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
provider (OON).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says hearing aids from an out-of-network provider are not 
covered.  
 
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 rendered by 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 request in this case is for 
hearing aids from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-
approve hearing aids to be rendered by an out-of-network provider (OON).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on June 12, 2023, by an out-of-
network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that the facility was responsible to obtain prior 
authorization and the treatment was medically necessary. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
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 a home health visit provided on June 12, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
and facial surgery (D7950) for tooth numbers 30 and 4. 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation (D7953) and facial surgery 
(D7950) for tooth numbers 30 and 4. You say that you would like to appeal the denial of these services. The 
Plan denied your request. The Plan says this is not a 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 pre-approve a 
bone replacement graft for ridge preservation (D7953) and facial surgery (D7950) for tooth numbers 30 and 4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 02, 2023, 
to March 25, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider was not responsible 
for obtaining authorization. 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 subsequent nursing 
facility care provided on March 02, 2023, to March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses. 
 You asked the Plan to pre-approve eyeglasses. You say that you did purchase a pair of glasses in April. You 
also say that now you currently cannot see out of the glasses. The Plan denied your request. The Plan says this 
benefit is exhausted. 
 
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 you have not already exhausted this benefit.  
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of eyeglasses (lenses and 
frames) yearly. The record shows that this benefit was exhausted on April 3, 2023. Based on this information, 
we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eyeglasses.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinvanti. 
 You asked the Plan to pre-approve Cinvanti. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Cinvanti. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug. There is no indication that the 
plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cinvanti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cinvanti.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 22, 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 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 15, 
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 the enrollee 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 periodontal maintenance (D4910) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on December 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the eye exam. You say that you were referred by your doctor to see the out-of-
network provider for continuation of emergency treatment.  The Plan denied your request. The Plan says the 
service was not urgent in nature, and you left the service area with the knowledge that a follow-up was required 
within two weeks of the initial check-up.  
 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 at issue in this case is not a network provider with the Plan. 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 eye exam. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found you were already diagnosed with a posterior vitreous detachment and retinal 
hemorrhage in the right eye one month prior with an in-network ophthalmologist. You traveled outside of the 
service area. There was no urgent or emergent condition, as there were no new examination findings, vision 
loss, or treatment required. Therefore, the eye exam was not urgent in nature and plan criteria is not met.  
 
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 eye exam have not been met.  
 
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 pay for the eye exam. Therefore, we decided that the Plan does not 
have to pay for the eye exam provided on December 13, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the walker (E0143) provided on March 8, 2023. 
 
You asked the Plan to pay for the walker (E0143). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the walker (E0143) based on Medicare criteria. The Local Coverage Determination and Article the 
Plan bases their denial on does not specifically state that the KX modifier must be billed with code E0143. 
Therefore, we decided that the Plan has to pay for the walker (E0143) provided on March 8, 2023.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
June 22, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. 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 and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic. You say that this item is medical necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro orthotic. Our reviewer says 
that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer 
found this item is not experimental and the medical record supports this enrollee's need for the requested 
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 a MyoPro orthotic have been met. Therefore, we decided that the Plan has to 
pre-approve a MyoPro orthotic (L8702).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the enrollee does not meet the medical necessity criteria for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. 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.  The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement; however, the documentation does not support that they would meet criteria for 
admission to an IRF.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain their functional status.  The member can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a intraoral x-ray, extraction, and bone replacement graft 
(D7140, D7953, D0220) provided on June 8, 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 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 a intraoral 
x-ray, extraction, and bone replacement graft (D7140, D7953, D0220) provided on June 8, 2023.