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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics were able to revive the enrollee and found no need to transport her to the hospital for further check. 
The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and to pay 
for the intraoral complete series of radiographic images (D0210) provided by an out-of-network provider on 
April 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that according to your benefits you should get 
50% back from the dental services. 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. Also, the intraoral complete series of 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. 
 
The total amount billed for the comprehensive oral evaluation (D0150) was $50 and the total allowable was 
$22 leaving a difference of $28 ($50 billed - $22 allowed). The total coinsurance amount was $11 ($22 allowed 
x 50% coinsurance). The total liability for the comprehensive oral evaluation (D0150) was $39 ($28 difference 
+ $11 coinsurance). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment along with a 50% coinsurance. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. The intraoral complete series of radiographic images are not covered under the Plans 
dental benefit. Therefore, we decided that the Plan does not have to pay more for a comprehensive oral 
evaluation (D0150) and to pay for the intraoral complete series of radiographic images (D0210) provided by an 
out-of-network provider on April 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical and occupational therapy to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve home health physical and occupational therapy. You say that that there are 
no in-network home health agencies able to provide these services to the enrollee. The Plan denied your 
request. The Plan says there are in-network providers available to the enrollee. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health physical and occupational therapy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant. 
You say that your prior dentist did not do a proper deep cleaning as it only lasted five minutes. You also say 
that your current symptoms have gotten worse. 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 periodontal scaling and root planing - four or more teeth per quadrant was exhausted 
on dates of service September 12, 2022, and September 24, 2022. Therefore, we decided that the Plan does not 
have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) and a bone replacement graft (D4263) 
for tooth #19 provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the entire 
implantation process. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the cone beam and a bone replacement graft 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 a cone 
beam (D0364) and a bone replacement graft (D4263) for tooth #19 provided on February 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic (CT) 
colonography provided on March 15, 2023. 
 
You asked the Plan to waive the copayment for a computed tomographic (CT) colonography. You say that you 
feel the copayment should be covered by the Plan. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomographic (CT) colonography. This 
item/service falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a computed tomographic (CT) colonography provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 15, 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 $2,100 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided from August 29, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider who billed for this service is not 
eligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the following provider types are eligible to 
receive Medicare payment: physicians, physician assistant, nurse practitioner, clinical nurse specialist, nurse 
midwife, and clinical psychologists. 
 
In this case, it appears as though the provider of the services at issue has two separate taxonomy codes: one that 
designates them as a Registered Nurse, and one that designates them as a Nurse Practitioner. For the claim in 
dispute, it was billed with the taxonomy for the Registered Nurse listing. Registered nurses are not permitted to 
bill under Medicare rules, which is why this claim cannot be paid. If you wish to submit a corrected claim with the Nurse Practitioner taxonomy code, you can do that with the Plan directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for the physician services provided from August 29, 2022, to August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided on April 
12, 2023. 
 
You asked the Plan to pay for the complete denture - maxillary. You say that your previous dentist used your 
ability to make a claim from this years benefit. You also say that this puts a great strain on you financially and 
are asking to restore your benefit for this year. The Plan denied your request. The Plan says your benefit for the 
complete denture - maxillary 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 complete denture - maxillary was exhausted on date of service August 30, 2022. Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided 
on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says you do not meet criteria for approval of the 
requested ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac ablation (93656). 
 
You asked the Plan to pre-approve cardiac ablation. 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 cardiac ablation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on current guidelines as well as the records provided, catheter ablation of atrial 
fibrillation would not be considered medically necessary in this 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 cardiac ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cardiac ablation (93656).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission based on medical necessity. The Plan denied your request. The Plan says that the medical 
necessity criteria have not been met. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing needs. You do have documented skilled 
therapy needs. You are functioning below your baseline and are unsafe for independent mobility. Education 
and training, of both you and your family, regarding mobilization and activities of daily living with a cervical 
collar, as well as evaluation for durable medical equipment needs, is warranted. Daily skilled services are 
required to establish a maintenance program or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a fitness membership fee provided on February 16, 2023. 
 
You asked the Plan to pay for fitness membership. You say that you have not received your reimbursement. 
The Plan denied your request. The Plan says that the Plan no longer issues direct-to-member fitness 
reimbursement, instead it falls under the Flex Card allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits. 
 
The Plans rules for coverage of gym benefits have been met because your contract with the Plan does not state 
that your fitness benefit expenses cannot be reimbursed directly to you, nor that payment for them is made 
through a flex card rather than conventional payment. You paid for this fitness membership up front and the 
Plan has not shown that it would be inappropriate to reimburse you directly for this covered expense. 
Therefore, we decided that the Plan has to pay for a fitness membership fee provided on February 16, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the records provided support the need 
for home health services. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the therapy 
notes show the enrollee has reached goals for balance and mobility. He had progressed from maximum assist 
for transfers and ambulation to minimal assist. He had shown little response to continued therapy once he 
reached minimal assist. Therapy had discharged him with goals met and a home exercise program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown - porcelain fused to high noble metal (D2752) provided on 
January 24, 2023.  
 
You asked the Plan to pay for the crown. You say that crowns are supposed to be covered at 50%. The Plan 
denied your request. The Plan says that dental necessity is not evident from submitted documentation.  
 
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 Plan covers the crown 
when the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the criteria 
for coverage have been met. Our physician reviewer found it was medically necessary for the enrollee's general 
to dentist to perform D2752 in order to stabilize the tooth and decrease risk of fracture. The clinical records 
were reviewed. The x-ray dated January 10, 2023, showed root canal treatment and a large amalgam restoration 
on tooth number 4. When there is a large existing restoration, and the natural tooth structure that is supporting 
the restoration is minimal, the tooth is at risk of fracture, and a full coverage crown is necessary to decrease 
risk of fracture for the tooth. This factor combined with the enrollee having root canal treatment done, a full 
coverage crown is warranted. In order to perform root canal treatment, a root canal specialist needs to create an 
access opening in order to do the root canal treatment. The coronal structure of the tooth is further weakened 
and further prone to fracture without a full coverage restoration being placed. The root canal specialist that 
performed the root canal treatment stated in his correspondence letter that the prognosis of tooth number 4 after 
root canal treatment was good, and recommended composite and crown as next treatment for the enrollee. I 
agree with the specialist that this would have been the next step for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pay for a 
crown - porcelain fused to high noble metal (D2752) provided on January 24, 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.