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

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need this denture. 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 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
15, 2023. 
 
You asked the Plan to pay for the ED services. You say that the claim is for an emergency room claim and you 
are not required to participate in Medicare. 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 emergency 
department (ED) services provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99213) provided 
on July 5, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that your chiropractic services have always 
been completely covered until you needed to find a new provider. The Plan denied your request. The Plan says 
this chiropractic service is excluded from coverage. 
 
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 the office visit provided by a chiropractor (99213) provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer (D2962) provided on May 10, 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 labial 
veneer (D2962) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 20, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees generally must receive their care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care provided on June 20, 2023, by an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy provided on February 7, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the bronchoscopy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the bronchoscopy provided on February 7, 2023, 
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deducible for an in-network diagnostic colonoscopy 
provided on July 26, 2023. 
 
You asked the Plan to waive the deducible for an in-network diagnostic colonoscopy. You say that this was a 
screening colonoscopy, not a diagnostic.  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. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient surgery. You have been 
asked to pay $522.31 towards the $525 2023 deductible.   
 
The item or service you asked the Plan to waive the deducible for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been 
met at the time an in-network diagnostic colonoscopy was received on July 26, 2023.  Therefore, we decided that the Plan does not have to waive the deducible for an in-network diagnostic 
colonoscopy provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
removal of residual tooth roots 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of residual tooth roots (D7250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940) provided on 
April 10, 2023 and June 20, 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 at issue in this case are not a 
covered benefit.  
 
The Plan must follow Medicare rules. 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 record shows that chiropractic maintenance care 
was provided in this case. Chiropractic maintenance care is not a Medicare covered benefit. Therefore, we 
decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940) provided on 
April 10, 2023 and June 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on April 13, 2023. 
 
  You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you were 
in an accident and the Plan paramedic came to you first. You also say they left so an outside paramedic has to 
be called. The Plan denied your request. The Plan says paramedic Intercept services are not covered under the 
members plan. The Plan also says that they do not have a contract with this ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for ambulance 
response and treatment, no transport (A0998) provided on April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 27, 2022, through May 4, 
2022 
 
You asked the Plan to pay for SNF care. You say that the services the enrollee received during this period were 
necessary and coverable. The Plan denied your request. The Plan says the enrollee no longer needed SNF care. 
The Plan also says that the enrollee was enrolled in hospice from April 29, 2022, to May 4, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. The rules say that the Plan may 
direct the provider to bill Medicare directly for these services. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs or skilled therapy needs from 
April 27, 2022, to April 28, 2022. The enrollee's needs could have been provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. The enrollee was under the Medicare hospice 
benefit from April 29, 2022, to May 4, 2022. Therefore, we decided that the Plan does not have to pay for SNF 
care provided from April 27, 2022, through May 4, 2022
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services physical therapy 
services on June 7, 2023. 
 
You asked the Plan to waive the copayment for physical therapy services physical therapy services. You say 
that you were told your copayment was $10 at the time of service. 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay $35 copayment for physical therapy services. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy services physical therapy services on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary/mandibular complete dentures (D5110, D5120) 
provided on March 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 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 
maxillary/mandibular complete dentures (D5110, D5120) provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (AFO) provided by an out-of-network 
provider on October 20, 2022. 
 
You asked the Plan to pay for an AFO. You say that your previous brace wore out and you needed a new brace. 
The Plan denied your request. The Plan says the requested item is not covered by Medicare when purchased at 
a retail store. 
 
The Plan must follow Medicare rules. Medicare rules say that no Medicare payment may be made to a 
beneficiary for items or services provided directly by a supplier or provider who has opted out of the program 
except in cases involving emergencies or urgently needed care.  
 
  We looked at the file and Medicare rules. Records indicate the item was received by a provider who is not a 
Medicare certified supplier, based on this information, we decided that Medicare rules for coverage of an AFO 
have not been met. Therefore, we decided that the Plan does not have to pay for an ankle foot orthosis (AFO) 
provided by an out-of-network provider on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that you need the denture as soon as possible 
because you are not eating. 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 complete lower denture (D5214) on January 14, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of January 14, 2021. Therefore, we decided that 
the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you accidentally threw your dentures away. 
You also say you cannot wait five years for another denture. 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 March 31, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and the extraspinal chiropractic 
manipulative treatment (98943) provided on May 1, 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 these services 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 Plan contract provides supplemental coverage 
for spine x-rays and chiropractic radiology services.   
 
The records show that the services at issue are not covered by Medicare or the Plan. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) and the extraspinal chiropractic manipulative 
treatment (98943) provided on May 1, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. 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 Entyvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided on 
November 23, 2022, to November 27, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day, days 1 to 6 and a $0 copayment per day, days 7 to 90 of inpatient hospital care. 
 
 
 You have been asked to pay a $325 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,300 ($325 copayment x 4 days = $1,300). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 reduce the copayment for an inpatient hospital stay provided on November 23, 2022, to 
November 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E1007, E2361 x2, 
E1028, E2620, E0955, E1028, E2300, E1012, and E2607). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee needs a powered mechanical seating system to position themself so they can be 
independent. You also say that the requested power wheelchair will allow the enrollee to safely and 
consistently complete their mobility related activities of daily living each day. The Plan denied your request. 
The Plan says the enrollee does not have a medical need for multiple power options available with a K0861 
group 3 power wheelchair. The Plan also says an expandable controller, harness and electronics are not 
medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has Parkinson's disease. The enrollee has moderate risk 
for skin breakdown, does not use a catheter, does not have spasticity limiting their positioning, and is able to 
use a standard joystick. Our reviewer also found that the enrollee does not have high risk for skin breakdown, 
use a catheter intermittently, have spasticity or require an alternative means of managing power drive. 
 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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E1007, E2361 x2, E1028, E2620, E0955, E1028, E2300, E1012, and E2607).