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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a CT cone beam 
capture (D0380), provided on February 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you had limits to services. 
The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 D0140 was exhausted on date of service January 17, 2023. D0380 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), 
and a CT cone beam capture (D0380), provided on February 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 09, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
March 09, 2023.
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 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
husband thought you were having a seizure so the ambulance was called.  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 18, 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 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on December 14, 2021. 
 
You asked the Plan to pay for ambulance service, conventional air services, transport, one way and air mileage. 
You say that that the services were medically necessary and are provided to everyone who needs them without 
regard to their insurance coverage. Provider submitted medical records for review. The Plan denied your 
request. The Plan says the claim was untimely, and the submission did not meet the exception criteria 
guidelines. 
 
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 ambulance service, conventional air services, transport, one way and air 
mileage was not filed until February 23, 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 
ambulance service, conventional air services, transport, one way and air mileage provided on December 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic service provided on January 26, 2023, to 
February 28, 2023. 
 
You asked the Plan to pay for chiropractic service. You say that it is medically necessary. The Plan denied your 
request. The Plan says they cover only manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic service provided on January 26, 2023, to February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride varnish (D1206) provided on April 13, 2023. 
 
You asked the Plan to pay for fluoride varnish. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 fluoride 
varnish (D1206) provided on April 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kesimpta. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kesimpta.   
Benefits for the medication 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 pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF. 
 
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 that 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 enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parathyroidectomy or exploration of parathyroid(s) 
(60500) provided on March 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the surgical service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan also says that the service was 
not urgent or emergent. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the 
Plan does not have to pay for the parathyroidectomy or exploration of parathyroid(s) (60500) provided on 
March 27, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan of whole body. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are medically necessary.  The 
Plan denied your request. The Plan says the documentation provided does not show physical exam results that 
show a reason this study is needed.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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/CT scan. Our reviewer says 
that the PET/CT scan is not medically necessary. Our physician reviewer found a computed tomography 
angiography (CTA) done on February 14, 2023, performed for chest pain and shortness of breath shows 
multiple small scattered sclerotic lesions favored as benign etiology such as bone islands but metastases are 
less likely a consideration. It is unclear why a PET/CT scan was ordered as the subsequent test. The enrollee 
does not have any history or primary cancer or strongly suspected solid tumors on imaging. 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/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan of whole body.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on January 1, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the Plan is responsible for a balance left 
after the enrollee's auto insurance paid. The Plan denied your request.  
 The Plan says the total cost of the claim is $1,658.00, and the member had a $200 deductible with their auto 
insurance carrier that was met and paid by the auto insurance carrier.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has concluded 
that the enrollees auto insurance paid the full charge of $1,658.00. $1,458.00 was paid towards the claim after 
the $200 deductible was met, leaving the Plan responsibility with $0. As the secondary insurer, the Plan cannot 
be held responsible for the ambulance services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support and 
ground mileage provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photo plastic lens, the polycarbonate lens, the anti-
reflective lens, the bifocal lens, and the frames provided on March 9, 2023. 
 
You asked the Plan to pay for the vision services. You say that you have been to this provider before, and that 
claim was paid. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the photo plastic lens, the polycarbonate lens, the anti-
reflective lens, the bifocal lens, and the frames provided on March 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 3, 
2023, to February 17, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are currently paying on other 
medical expenses and cannot afford to pay another copayment. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per day for days 1 to 20, an $80 copayment per day for days 21 to 44, and $0 copayment for days 
45 to 100 for SNF care.  
 You have been asked to pay a $1,120 copayment for a SNF stay ($80 per day x 14 days = $1,120). This 
item/service falls within the SNF 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 a 
SNF stay provided from February 3, 2023, to February 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you think it would benefit you to see the 
OON provider. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 
physical therapy to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 10, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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.  
 
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 pay for the pneumatic compression device provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic service provided on February 8, 2023. 
 
You asked the Plan to pay for chiropractic service. You say that you are appealing the $85 extra copayment. 
The Plan denied your request. The Plan says chiropractic services other than the manual subluxation of the 
spine are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic service provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hydrophilic spherical contact lenses provided on October 
12, 2022. 
 
You asked the Plan to pay for the contact lenses. You say that the Plan will pay up to $100 for eyeglasses or 
contact lenses. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not listed as a covered benefit. Based on 
this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the hydrophilic spherical contact lenses provided 
on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 16, 2023, provided by an 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were never told that 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 on March 16, 2023, provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the impact-resistant lenses, the anti-glare, the ultraviolet 
backside, and the rimless mounting and to waive the copayment for the eyeglasses provided on March 1, 2023. 
 
You asked the Plan to pay for the vision services. You say that the denied items should be covered. You say 
that the provider did not tell you that the prescription lenses and frames would not be covered. The Plan denied 
your request. The Plan says the services are not covered benefits and the copayment applied correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when not covered. 
 
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 $20 
copayment for standard single vision, lined bifocal, and lined trifocal lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered enhancements and not 
covered services. Based on this information, we decided that the Plan's rules for coverage of the vision services 
have not been met. 
 
You have been asked to pay a $20 copayment for the eyeglasses. This item falls within the supplemental vision 
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 pay for the impact-resistant lenses, the anti-glare, the 
ultraviolet backside, and the rimless mounting and to waive the copayment for the eyeglasses provided on 
March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on February 6, 2023. 
 
You asked the Plan to pay for chiropractic treatment. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic treatment provided on February 6, 2023.