Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 11, 2023, through February 2, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on January 11, 2023, through February 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for colonoscopy and office visit on March 13, 
2023. 
 
You asked the Plan to waive the copayments for colonoscopy and office visit. You say that you want to appeal 
the amount being charged. 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 each Medicare-covered outpatient surgical service (including diagnostic colonoscopies). 
Covered services include but are not limited to services in an emergency department or outpatient clinic, such 
as observation services or outpatient surgery. You must pay a $40 copay for each Medicare-covered specialist 
visit. Covered services include consultation, diagnosis, and treatment by a specialist. For both services it's, 
$350 + $40 = $390. Therefore, results in the total cost sharing amount of $390. 
 
You have been asked to pay a $350 copayment for colonoscopy and a $40 copayment for office visit. This 
item/service falls within the outpatient hospital services and physician/practitioner services, including doctors 
office visits 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 copayments for colonoscopy and office 
visit on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the current acute care 
hospital can provide acute care services until the enrollee is ready for transfer to an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found at the time of the request for admission to a LTACH the enrollee is medically 
unstable for transfer due to an abnormal chest x-ray findings requiring frequent suctioning. The enrollee is also 
neurologically unstable due to a severe anoxic brain injury with decerebrate posturing unresponsive to sternal 
rub. The enrollee can continue receiving care at the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic evaluation (D0120) and the cleaning (D1110) 
provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had out-of-network benefits in 2022. You 
say someone should have told you during open enrollment when you asked if there were going to be any 
changes to the plan for 2023. 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 evaluation (D0120) and the cleaning (D1110) provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, Diphtheria Toxoids and Acellular Pertussis 
(Tdap) vaccine you received on May 23, 2023. 
 
You asked the Plan to pay for the Tdap vaccine. You say that your doctor's office gave you this shot and did 
not put the charge under Part D. The Plan denied your request. The Plan says this specific vaccine is not 
covered under your medical benefits.  The Plan has provided you with information regarding how you can 
submit this claim to your Part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, Diphtheria Toxoids and Acellular 
Pertussis (Tdap) vaccine you received on May 23, 2023.  
 
Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 11, 2023, to February 15, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel that the 
services with both hospitals should be considered as one continuous hospitalization. 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 each day, for days 1 to 5, for Medicare-covered hospital care each time you are admitted. 
 
 You have been asked to pay a $1000 copayment for the inpatient hospital stay ($250 copayment x 4 days = 
$1000). 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 waive the copayment for the inpatient hospital stay provided from February 11, 2023, to February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing service, miscellaneous (V5299), 
sales tax (S9999), and the hearing aids (V5298) purchased on April 24, 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 these items are not payable as 
they were purchased from an out-of-network 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 purchased from the Plans select hearing aid provider.  
 
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 hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing service, miscellaneous (V5299), sales tax (S9999), and the hearing aids (V5298) 
purchased on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954) 
provided on May 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were informed by the Plan's representative 
this service was covered. The Plan denied your request. The Plan says this is not a covered service 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. 
 
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 
prefabricated post and core in addition to crown (D2954) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral - periapical first radiographic image 
(D0220), resin-based composite - one surface, posterior (D2391), periodontal scaling and root planing - one to 
three teeth per quadrant (D4342) provided on March 9, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D0220, D2391 and D4342. You 
say that you were informed by your dentist that you would owe $0 but then received a bill stating you owe 
$220 plus after paying $154 out-of-pocket. You also say that you have a $500 deductible you would like to use, 
and you have been going to this dentist for 15 years and do not plan to go to another. 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.  
 
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.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for an intraoral - periapical first radiographic 
image (D0220), resin-based composite - one surface, posterior (D2391), periodontal scaling and root planing - 
one to three teeth per quadrant (D4342) provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp cap - indirect (excluding final restoration) (D3120) 
provided on March 20, 2023. 
 
You asked the Plan to pay for the pulp cap - indirect. You say that you do not agree with the denial for the 
dental service. The Plan denied your request. The Plan says this is not a covered service 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. 
 
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 pulp cap - 
indirect (excluding final restoration) (D3120) provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on May 12, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the eye exam. 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 eye exam provided on May 12, 2023, by an 
OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the MRI. You say that this is where your provider has requested you to get 
the imaging done. The Plan denied your request. The Plan says there are network providers available. 
 
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 
a magnetic resonance imaging (MRI) of the abdomen to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization, per site (D7922), and local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was a medical emergency and the local 
anesthesia denied was necessary to remove the dangling bridge. You also say that you are requesting to 
reconsider the decision and approve these procedures that were denied. The Plan denied your request. The Plan 
says procedure codes D7922 and D9215 are not listed as covered 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the placement of 
intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922), and local anesthesia 
in conjunction with operative or surgical procedures (D9215) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge prevention (D7953) and 
the guided tissue regeneration (D4267) provided on May 11, 2023. 
 
You asked the Plan to pay for the bone replacement graft for ridge prevention (D7953) and the guided tissue 
regeneration (D4267). You say that the denied claim is not only a financial burden but also limits the care you 
need for the rest of your life. The Plan denied your request. The Plan says the services are not covered 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 the bone 
replacement graft for ridge prevention (D7953) and the guided tissue regeneration (D4267) provided on May 
11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a customized pediatric sized wheelchair/stroller 
(E1232). 
 
You asked the Plan to pre-approve  a customized pediatric sized wheelchair/stroller. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. 
 
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 customized pediatric sized wheelchair/stroller. Our reviewer says that the item is not medically necessary. Our physician reviewer found 
this device has been requested for community transport and will not be used in the home. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve  a customized pediatric sized wheelchair/stroller (E1232).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implants (D6010) on tooth #s 21, 
28. 
 
You asked the Plan to pay for the surgical placement of implants (D6010) on tooth #s 21, 28.. You say that you 
needed these implants to help your dentures. You say you saw no other option. The Plan denied your request. 
The Plan says the services are not covered 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 the 
surgical placement of implants (D6010) on tooth #s 21, 28.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 2, 
2022, through October 4, 2022. 
 
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 you have not provided sufficient information 
to substantiate the medical necessity of the services provided.  
  
 
 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.  
Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
October 2, 2022, through October 4, 2022.
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 enrollee has presented a short-term memory 
loss and cognitive decline over the last year and a half. 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 suspected of possibly 
having AD. However, they do not readily meet diagnostic criteria for this disorder. There is no indication that 
the requirement criteria for FTD have been met. The request cannot be approved at this time. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy (29826, 29824, 29828, 29827) provided on 
December 6, 2022. 
 
You asked the Plan to pay for the surgical services. You say that these services should be covered. The Plan 
denied your request. The Plan says you are not enrolled in Medicare. The Plan says you are not eligible to 
enrollee in Medicare. The Plan also says that payment cannot be made for services performed by a provider 
that is not enrolled in Medicare. 
 
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 arthroscopy (29826, 29824, 29828, 
29827) provided on December 6, 2022.