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

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
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 December 15, 2022.   
 
 
 
Specifically, the Plans contract states that one upper and lower partial denture are covered every 60 months. 
You previously received these dental items on December 15, 2022, less than 60 months prior, which were paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental items in this case.  
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower 
partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bath/shower chair.  
 
You asked the Plan to pay for a bath/shower chair. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a bath/shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on November 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extractions, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210 x 6) and the bone replacement grafts for ridge 
preservation-per site (D7953 x4) provided on December 7, 2022. 
 
You asked the Plan to issue reimbursement for the dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental 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 issue reimbursement for 
the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 6) and the 
bone replacement grafts for ridge preservation-per site (D7953 x4) provided on December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 clinical 
documentation shows that there have been medication/monitoring changes however documentation does not 
support skilled nursing services in the home setting to effectively provide treatment, care, and/or services in 
order to improve your condition, or to establish/perform a maintenance program to maintain your condition 
and/or prevent deterioration. Clinical documentation does not show that you are home bound.  
 
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 skilled nursing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
procedure (0275T). 
 
You asked the Plan to pre-approve the MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the facility where the member was referred 
to, Broward Health Imperial Point is not a participating location for the Medicare approved clinical study. 
 The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MILD procedure have not been met. Specifically, the facility where the member was referred 
to, Broward Health Imperial Point is not a participating location for the Medicare approved clinical study. 
Therefore, we decided that the Plan does not have to pre-approve the minimally invasive lumbar 
decompression (MILD) procedure (0275T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary for the 
enrollee who has clinical features of cognitive impairment which can be present in either Alzheimer's disease 
or frontotemporal dementia. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is noted to have a history of a 
progressive cognitive impairment. However, they are not noted to meet diagnostic criteria for either, let alone 
both AD and FTD. The provider's notes indicated a larger suspicion for AD. There was no demonstration that 
diagnostic criteria for either syndrome were all satisfied. 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
3, 2021, to November 11, 2021. 
 
You asked the Plan to pay for SNF care. You say that your initial claim was submitted on time but was denied 
incorrectly. The Plan denied your request. The Plan says the corrected claim was filed after the timely filing 
limit without good cause. 
 
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 SNF care was not filed until February 28, 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 skilled nursing facility (SNF) care provided from November 3, 2021, to 
November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on January 
17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you have had face pain for years and the shots 
worked to relive your pain. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the therapeutic parenteral drug 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 pay for the 
therapeutic parenteral drug (D9610) provided on January 17, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 9, 2023. 
 You asked the Plan to pay for the ambulance service. You say that the services should be covered by the Plan. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware this provider was out-of-
network. 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 dental services provided by an out-of-network provider on April 18, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for OT evaluation provided on May 2, 2023. 
 
You asked the Plan to waive the copayment for OT evaluation. You say that the therapy copayment should fall 
under the procedure copayment and not be an extra charge. The Plan denied your request. The Plan says that 
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 enrollees must pay $0 copayment for a post outpatient surgical procedure 
physical therapy or occupational therapy consultation prior to discharge.  
 
The Plan says you must pay a $40 copayment for OT evaluation. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for OT evaluation following an outpatient surgical procedure. 
On May 1, 2023, you had a full knee replacement followed by an OT evaluation prior to discharge. Therefore, 
we decided that the Plan has to waive the copayment for OT evaluation provided on May 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) Tooth #4 and 5 and 
retainer crown - porcelain/ceramic (D6740) Tooth #3 and 6. 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says these services are not covered under your 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. Pontic - porcelain/ceramic 
(D6245) and retainer crown - porcelain/ceramic (D6740) are not covered under the Plans dental benefits 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6245 and D6740 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain/ceramic (D6245) Tooth #4 and 5 and retainer crown - porcelain/ceramic (D6740) Tooth #3 
and 6.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial nursing facility care visit provided on April 3, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an initial nursing facility care visit. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. 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 an initial nursing facility care visit provided on 
April 3, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950). 
 
You asked the Plan to pre-approve D2950. You say that the dental services requested are to replace old dental 
work. The Plan denied your request. The Plan says this claim has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core build-up (D2950).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visit provided on May 3, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for subsequent nursing facility care visit. You say that the treatment provided was 
medically necessary. The Plan denied your request. The Plan says an authorization was not obtained prior to 
services rendered. 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 subsequent nursing facility care visit provided on 
May 3, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x4). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 clinical 
documentation does not show any recent medication, plan of care changes, vitals/condition stable thus the 
records do not support skilled nursing services in the home setting to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
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 skilled nursing (G0299 x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extractions (D7140) for tooth #1 and 
#2 provided on January 31, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you want to be reimbursed 
for the dental expenses. 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 50% 
coinsurance for an extraction. For each extraction the total allowed amount was $100 with a coinsurance of $50 
($100 allowed x 50% coinsurance). The total coinsurance amount for both extractions was $100 ($50 
coinsurance x 2 extractions). 
 
  You have been asked to pay a $100 coinsurance for the extractions. This item/service falls within the  
Covered Dental Services Chart 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 coinsurance for 
the extractions (D7140) for tooth #1 and #2 provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy service. You say that the massage therapy was a necessary 
and made in accordance with Medicare guidelines and is part of a physical therapy program. You also say that 
the denial is in error and deceptive. The Plan denied your request. The Plan says massage therapy is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.