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

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) 
provided on July 24, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service January 24, 2023.  
  
 
 
 
 
Specifically, the Plans contract states that one set of bitewing x-rays are covered every calendar year. You 
previously received this service on January 24, 2023, less than one year prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does 
not have to pay for the bitewing x-rays-four radiographic images (D0274) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency dental services provided on April 24, 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 the cost-sharing applied correctly based on the 
services provided. Additionally, this benefit does not include extractions. 
 
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 a $75 copayment for emergency dental core. This item/service falls within the 
Emergency 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 emergency dental services provided on 
April 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 23, 2023, to April 18, 
2023. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was transported due to a 
hemorrhage of a surgical site. 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 ambulance services provided on March 23, 2023, to April 18, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on 
February 01, 2023, to February 04, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you were not expecting 
any copays higher than what they had planned for. 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 $140 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $140 copayment for skilled nursing facility. This item/service falls within the Skilled nursing facility (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. You have been asked to pay a total of $140 for skilled nursing facility ($20 x 3 
for days 18-20 + $80 for day 21 = $140). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on February 01, 2023, to February 04, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on May 31, 
2023. 
 You asked the Plan to pay for SNF services. You say that the enrollee ended their hospice benefits on May 28, 
2023, and the services were rendered on May 31, 2023. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 28, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
(SNF) services provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 23, 
2022. 
 
You asked the Plan to pay for the office visit. You say that the stimulator was used to aid the relief of lower 
back pain. The Plan denied your request. The Plan says that the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 the office visit provided by a chiropractor on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97012, 97112,97110) provided 
by a chiropractor on May 9, 2023, to, June 30, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that there are physical therapist in the 
facility. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 the physical therapy services (97012, 97112,97110) provided by a 
chiropractor on May 9, 2023, to, June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures (D5120, 
D5110). 
 
You asked the Plan to pre-approve 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 November 8, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary/mandibular dentures 
(D5120, D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 10, 2023. 
 
You asked the Plan to pay for office visit. You say that the services were medically necessary. 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 office visit provided on 
May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on May 26, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
comprehensive series of radiographic images (D0210) provided on May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has multiple complex 
medical issues that cannot be managed at a lower level of care and will need ongoing daily physician 
management. The Plan denied your request. The Plan says that an LTACH admission is not medically 
necessary.  
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee requires close monitoring due to high risk for recurrence of their white out 
lung. The enrollee also has therapy needs and is expected to improve and need LTACH level of care for about 
25 days. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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 pay for subsequent nursing facility care, and related services 
provided on May 18, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that the enrollee 
could not choose an in-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 subsequent nursing 
facility care, and related services provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluation (D0150) and the 
surgical removal of erupted tooth requiring the removal of bone (D7210). 
 
You asked the Plan to pay more for the dental services. You say that your provider referred you to this provider 
when he was unable to remove the root of a tooth you broke. 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 comprehensive oral evaluation (D0150) and 
the surgical removal of erupted tooth requiring the removal of bone (D7210).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 13, 2021, 
to February 14, 2021. 
 You asked the Plan to pay for the emergency room services. 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 emergency room services provided on February 13, 2021, 
to February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that this dentist was in-network. 
The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service June 13, 2023. Therefore, 
we decided that the Plan does not have to pay for dental services provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with single power option (tilt, 
legrests) and accessories. 
 You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the notes do not show 
that the enrollee has a medical need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain criteria are met. 
 
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 Group 3 power wheelchair with single 
power option. Our reviewer says that the requested Group 3 power wheelchair with single power option is 
medically necessary. Our physician reviewer found the provided documentation indicates the enrollee is non-
ambulatory and cannot use a cane or walker for mobility. They cannot functionally propel a manual wheelchair 
due to upper extremity weakness and lack of coordination. They are unable to operate a power scooter due to 
an inability to transfer and sit independently. The enrollee requires a power wheelchair for mobility and 
accomplishing their daily activities. The enrollee requires power tilt for pressure relief since they do not have 
the upper extremity strength to independently perform this. They require assistance for positioning and bed 
mobility. The enrollee requires power articulating leg rests for positioning of their lower extremities. They 
require a Group 3 power wheelchair base given the complexity of their positioning and seating needs and 
cannot use a Group 2 power wheelchair given their lack of trunk control and ability to re-position themselves. 
Therefore, the reviewer found that the requested Group 3 power wheelchair with power tilt and power 
articulating platform is medically 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 a Group 3 power wheelchair with single power option have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 3 power wheelchair with single power option 
(tilt, legrests) and accessories.  
 
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 pay for  the office visit (99202) and the chiropractic manipulative 
treatment (98941) provided by a chiropractor on May 24, 2023, to June 2, 2023. 
 
You asked the Plan to pay for  the office visit (99202) and the chiropractic manipulative treatment (98941). 
You say that you think the provider put in the wrong code. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. The Plan also says the remaining service is denied as it is not a covered 
service when provided by a chiropractor. 
 
  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 $20 
copayment for chiropractic services.  
 
You have been asked to pay $20 copayment for the office visit (99202) and the chiropractic manipulative 
treatment (98941). This item/service falls within the chiropractic services 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 office visit (99202) and the chiropractic manipulative treatment (98941) provided 
by a chiropractor on May 24, 2023, to June 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that the enrollee would prefer not to self-inject and has 
been very adamant about this, which is why you have chosen to go with Evenity. The Plan denied your request. 
The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
criteria for coverage of Evenity have not been met. Our physician reviewer found the Plan requires a trial of 
Forteo before they will approve the requested drug, Evenity. Based on the medical records provided, there is no 
indication that the enrollee has tried and failed the required drug. Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that the Plan's required drug would likely 
be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with field of 
view of one full dental arch  maxilla, with or without cranium (D0366) provided on July 17, 2023. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you upgraded your 
plan however it is not showing in the system. The Plan denied your request. The Plan says we confirmed that 
the (D0366) cone beam CT capture and interpretation is not listed as a covered benefit with your preventive or 
comprehensive option. 
 
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 cone 
beam CT capture and interpretation with field of view of one full dental arch  maxilla, with or without 
cranium (D0366) provided on July 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the heart with 
evaluation of blood vessel calcium received on March 1, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the CT scan was medically necessary. The Plan denied 
your request. The Plan says this type of scan is not covered when used for screening purpose. 
 The Plan must follow Medicare rules. Medicare rules say that the Plan must cover services that are medically 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a 
computed tomography (CT) scan of the heart with evaluation of blood vessel calcium received on March 1, 
2023.