Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 12, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the documents provided support the services 
rendered from an out-of-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 physical therapy 
provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional pontics and retainer crowns (D6750, D6240) 
provided on April 6, 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 April 6, 2023. Therefore, 
we decided that the Plan does not have to pay for additional pontics and retainer crowns (D6750, D6240) 
provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the assistive listening devices (V5267 x 2) 
purchased on April 25, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says assistive listening devices are not 
a covered benefit.  
 
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.  
 
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 coverage for hearing 
devices are limited to those worn externally and do not include assisted listening devices, amplifiers, or 
disposable devices. Therefore, we decided that the Plan does not have to issue reimbursement for the assistive 
listening devices (V5267 x 2) purchased on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 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 48 one-way transportation trips when each one-way trip does not exceed 50 miles.  
 
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 routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings provided by a non-certified 
Medicare provider on August 2, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that your physician ordered the compression 
stockings. The Plan denied your request. The Plan says the items were provided by a non-Medicare certified 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the compression stockings provided by a 
non-certified Medicare provider on August 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network skin debridement procedure 
provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network skin debridement procedure. You say that this 
was not done in an operating room, and you should not be charged as if you were. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities, and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for an in-network skin debridement procedure. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities, and 
ambulatory surgical centers 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 in-
network skin debridement procedure provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on July 19, 
2023 
 
You asked the Plan to pay for the dental services. You say that you thought some of the services would be 
covered. You also say that previously performed services by this provider had been covered. 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 periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic 
image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four 
radiographic images (D0274), and prophylaxis - adult (D1110) provided on July 19, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve an acute inpatient hospital admission. You say that you are requesting 
reconsideration of approval for this inpatient admission based on medical necessity of the care provided, and 
reimbursement for care rendered. The Plan denied your request. The Plan says the enrollee does not have an 
active coverage with the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if coverage under an MA plan begins while the 
beneficiary is an inpatient in a hospital facility, payment for inpatient services until the date of the beneficiarys 
discharge is made by the previous MA organization or original Medicare, as appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an acute inpatient hospital admission have not been met. Specifically, the records show that the 
enrollee was admitted on December 24, 2022, and that the enrollee was not active with the Plan on this date. 
Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on May 11, 
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 11, 2023. Therefore, 
we decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on May 11, 
2023.
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 enrollee has rehab goals that include returning to 
their prior level of function with assistance/care provided by their family. An admission to IRF is required as 
the enrollee's current needs cannot safely be met at a lower level of care The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to care for themself and 
needs to get stronger before they can safely go home. The Plan denied your request. The Plan says the enrollee 
does not need therapy or nursing services every day that are only on an inpatient basis in a SNF.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation MAKOplasty 
(0055T). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation MAKOplasty. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
MAKOplasty for robotic assistance in the setting of total joint arthroplasty has not been demonstrated in the 
peer-reviewed literature. 
 
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 computer-assisted surgical navigation 
MAKOplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no large volume, long-term/high-quality clinical 
studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of 
computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation MAKOplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation 
MAKOplasty (0055T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5011, V5261, V5160) provided on May 26, 
2023. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aid should be covered. The Plan denied 
your request. The Plan says the hearing aids are not a covered benefit as they were provided by a non-
contracted provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from a plan contracted TruHearing provider. 
 
We looked at the file and the Plan's rules. The hearing aids were not obtained from a TruHearing provider. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids (V5011, V5261, V5160) provided on 
May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the enrollee has been having issues with the 
Dexcom G6 sensor falling off and not adhering to their skin. The Plan denied your request. The Plan says that 
the clinician does not state the Dexcom G7 is medically necessary who already has a duplicate service from the 
G6 branded DME.  
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7. Our reviewer says that 
this item is medically necessary. Our physician reviewer found you are on two types of insulin and hence 
qualifies for CGM use and coverage. The G6 is not adhering well and the G7 sensor is smaller. It is reasonable 
to try the G7 to see if the sensor will adhere to the skin better and not fall off. 
 
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 Dexcom G7 have been met. Therefore, we decided that the Plan has to pre-
approve a Dexcom G7 continuous glucose monitor (CGM) sensor.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that this is 
necessary for the enrollees chronic pain. 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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ 
investigational procedure. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), a 2D photographic 
image (D0350), the guided tissue regeneration (D4266) for tooth #11, a partial upper denture (D2820), an 
extraction (D7210) for tooth #11, and a bone replacement graft (D7953) for tooth #11 provided on May 3, 
2023, and May 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you showed your coverage to the provider and 
and you did not have any knowledge about the dental implant. The Plan denied your request. The Plan says 
your maximum dental benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $500 for dental services on May 3, 2023; therefore, your annual dental maximum benefit 
for the year of 2023 was exhausted on the date of service of May 3, 2023. Therefore, we decided that the Plan 
does not have to pay for a panoramic radiographic image (D0330), a 2D photographic image (D0350), the 
guided tissue regeneration (D4266) for tooth #11, a partial upper denture (D2820), an extraction (D7210) for 
tooth #11, and a bone replacement graft (D7953) for tooth #11 provided on May 3, 2023, and May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226) provided on June 23, 2023. 
 
You asked the Plan to pay for the mandibular partial denture. You say that your dentures have broken, are 
uncomfortable and you cannot eat properly. You also say that you want the bill to be covered so you can get 
your dentures repaired without being required to wait 5 years. The Plan denied your request. The Plan says 
your benefit for the mandibular partial denture - 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 mandibular partial denture - was exhausted on date of service March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - flexible base 
(including retentive/clasping materials, rests, and teeth) (D5226) provided on June 23, 2023.