Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 02, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was in a nursing home and 
could not choose a network provider. 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 nursing facility care 
provided on March 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillofacial MRI image capture (D0385) provided on 
February 1, 2023. 
 
You asked the Plan to pay for the maxillofacial MRI image capture. You say that the computed tomography 
was performed as a necessary service toward you dental/overall health. You also say that it was your 
understanding that this service would be  provided and no indication of the contrary was ever told you or your 
spouse. The Plan denied your request. The Plan says you are only covered for the services and limits listed. 
Any dental services that are furnished, that are not listed as a covered service, or if you exceed the maximum 
service limit or annual maximum, will not be covered by the Plan and you will be responsible for the full cost. 
 
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 
maxillofacial MRI image capture (D0385) provided on February 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on March 7, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you did not call the 
ambulance and you should not be held responsible for the charges. The Plan denied your request. The Plan says 
the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
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 March 7, 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 ambulance treatment without transport provided 
on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth guard (E1399). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee is grinding their teeth and the 
requested item is medically necessary. The Plan denied your request. The Plan says the requested item is not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
mouth guard (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941 x 2) 
provided on May 19, 2023. 
 
You asked the Plan to pay 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 the services provided were billed as 
maintenance therapy, which 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 rules say that Medicare does not cover 
chiropractic maintenance care.  
 
 
 
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic manipulative treatments provided 
in this case are considered maintenance therapy as billed. Maintenance therapy is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatments  
(98941 x 2) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional complete mandibular denture reline (D5751) 
provided on May 1, 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 May 1, 2023. Therefore, 
we decided that the Plan does not have to pay for an additional complete mandibular denture reline (D5751) 
provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital, monaural, hearing aids provided on February 21, 
2023. 
 
You asked the Plan to pay for digital, monaural, hearing aids. You say that you were not made aware that this 
provider was not accepting the insurance. You also say that the hearing aids you did purchase have not been 
evaluated to suit your needs just yet either. The Plan denied your request. The Plan says this service is not a 
covered benefit according to the terms of your contract or is a specific exclusion of your coverage. 
 
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 The Plan rules say that this benefit is limited to preferred  hearing aids, which come in 
various styles and colors. The Plan rules also say that you must use a network provider to use this benefit. The 
record shows the hearing aids you obtained are not a preferred hearing aid, nor were they obtained through a 
Plan hearing provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of digital, monaural, hearing aids have not been met. Therefore, we decided that the Plan does not 
have to pay for digital, monaural, hearing aids provided on February 21, 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 you need these compression 
stockings. The Plan denied your request. The Plan says this compression stocking is not covered. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95939, 95938, 95861, and 95940 provided 
on March 21, 2023. 
 
You asked the Plan to pay for procedure codes 95939, 95938, 95861, and 95940. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was billed with 15, a mobile unit place of service code. 
The place of service code should reflect the actual place where the enrollee receives the face-to-face service. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 95939, 95938, 95861, and 
95940 provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces or 
involving incisal angle (anterior) (D2335) provided on May 3, 2023. 
 
You asked the Plan to pay for the resin-based composite. You say that you are requesting reconsideration for 
the denied service. 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 the resin-based composite - four or more surfaces 
or involving incisal angle (anterior) (D2335) provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 provided on 
March 30, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 
provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212), physical or manipulative therapy 
performed for maintenance rather than restoration (S8990), x-ray exam of the spine (72020), and the non-
covered items/services (A9270) provided from November 9, 2022, through February 7, 2023.  
 
You asked the Plan to pay for these items/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 items/services provided are 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 items/services at issue are not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for the office visit (99212), physical or manipulative therapy 
performed for maintenance rather than restoration (S8990), x-ray exam of the spine (72020), and the non-
covered items/services (A9270) provided from November 9, 2022, through February 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested genicular nerve block is considered experimental in nature. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service March 4, 2021.  
  
 
 
 
 
Specifically, the Plans contract states that complete dentures are covered once per arch, every 60 months. You 
previously received these dental items on March 4, 2021, less than 60 months prior, which were paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the requested items in this case at this time. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6999). 
 
You asked the Plan to pre-approve the dental services. You say that you should be able to choose to pay the 
difference between a bridge and implants so you can have a better outcome. The Plan denied your request. The 
Plan says the denial of authorization for these services is correct, because implants 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 pre-approve 
dental implants (D6999).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array; 
peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator. You say that this is medically 
necessary. The Plan denied your request. The Plan says that records do not show that this is a procedure of late 
or last resort as the enrollee has further nerve blocks and possible radiofrequency ablation planned. In addition, 
the documentation lacks a multidisciplinary evaluation including surgical, physical, and psychological 
therapies. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of stimulators can be covered under 
specific conditions. 
 
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 percutaneous implantation of 
neurostimulator. Our reviewer says that the service is medically necessary. Our physician reviewer found the 
enrollee had a left shoulder reverse arthroplasty. The enrollee has chronic severe pain and has had 
suprascapular nerve blocks. The enrollee is taking Gabapentin and has had physical therapy. There is a 
psychological evaluation in the record which clears him for the procedure. This procedure is standard of care 
for complex regional pain syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator have been met. Therefore, we 
decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array; 
peripheral nerve (excludes sacral nerve) (64555).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (93228, 
93229). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 external mobile cardiovascular 
telemetry. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has episodic palpitations. There is no 
supportive evidence that the ordering practitioner documented any standard, non-mobile cardiac outpatient 
telemetry, or ambulatory electrocardiogram monitoring.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (93228, 93229).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-autogenous connective tissue graft (D4275) for 
tooth #8 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary and if your problem is not corrected it will severely affect your diet and tooth loss. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct, because the non-autogenous 
connective tissue graft is 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 pre-approve the 
non-autogenous connective tissue graft (D4275) for tooth #8 and #10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block is experimental for knee pain. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 26, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the original claim was paid and recouped. 
The services were medically necessary. The Plan denied your request. The Plan says the claim was not filed 
within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until March 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that you have a sinus infection, so you need 
transportation. The Plan denied your request. The Plan says you have exceeded your Plan benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips.