Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 3 miles for a total of 53 miles of one-way 
routine transportation. 
 
You asked the Plan to pre-approve the additional miles. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that they allow routine transportation trips of up to 50 miles. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation trips of up to 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 3 miles for a total of 53 miles of one-way routine 
transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the overdenture  complete mandibular (D5865). 
 
You asked the Plan to pre-approve the overdenture  complete mandibular. You say that when you joined the 
plan, they informed you were covered for dental implants, crowns, and dentures, one time in a 5 year period. 
You also say that the plan approved the upper denture but not the bottom one. The Plan denied your request. 
The Plan says code D5865 is a non-covered code per the EOC. 
 
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 the 
overdenture  complete mandibular (D5865).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the guided tissue regeneration, natural teeth-resorbable barrier, per site 
(D4266) provided on January 9, 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 that you do not meet criteria for coverage of 
the service provided.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that you do not meet criteria for coverage of the 
service provided in this case as an apicoectomy was performed on the same day. However, the Plans contract 
does not indicate this exclusion of coverage. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to pay for the guided tissue regeneration, natural 
teeth-resorbable barrier, per site (D4266) provided on January 9, 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 pay for the surgical extraction (D7210), deep sedation/general 
anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each subsequent 15-minute increment 
(D9223 x 2) provided on April 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency procedure. The Plan 
denied your request. The Plan says these services are not covered benefits under your medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), 
deep sedation/general anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each 
subsequent 15-minute increment (D9223 x 2) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214 and D5226), a partial 
upper denture (D5225), and a reline of a partial lower denture (D5761). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a partial upper denture (D5225) and a partial lower denture (D5226) on August 5, 
2022; therefore, your benefit for the partial lower denture (D5214 and D5226) and the partial upper denture 
(D5225) was exhausted on the date of service of August 5, 2022. The record also shows that the Plan paid for a 
reline of a partial lower denture (D5761) on May 4, 2022; therefore, your benefit for the reline of a partial 
lower denture (D5761) was exhausted on the date of service of May 4, 2022. Therefore, we decided that the 
Plan does not have to pre-approve a partial lower denture (D5214 and D5226), a partial upper denture (D5225), 
and a reline of a partial lower denture (D5761).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203), electrical simulation (G0283) and 
ultrasound therapy (97035) provided by a chiropractor on May 17, 2022. 
 
You asked the Plan to pay for an office visit, electrical stimulation, and ultrasound therapy. You say that the 
only defense is that you did not question the lab your doctor sent you to. You say that you were told that you 
have another serious condition. 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 an office visit (99203), electrical simulation (G0283) and ultrasound therapy 
(97035) provided by a chiropractor on May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the records do not show the enrollee's smoking history. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the records do not include your tobacco smoking 
history. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2023, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81334, 81479, 81218, 
81314, 81345, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 23, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
81334, 81479, 81218, 81314, 81345, and 81272.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
March 16, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you switched to a different 
dentist and you were told the services were not approved. You also say that you had no idea that the provider 
had opted out of your dental plan. The Plan denied your request. The Plan says your benefit for the panoramic 
radiographic image 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 panoramic radiographic image was exhausted on date of service February 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital, monaural hearing aids (V5257) provided on May 2, 
2023. 
 
You asked the Plan to pay for digital, monaural hearing aids (V5257). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the item was not purchased through the Plan 
hearing network. 
 
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 the hearing aids are obtained through the Plan hearing network. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of digital, monaural hearing aids (V5257) have not been met. Therefore, we decided that the Plan 
does not have to pay for digital, monaural hearing aids (V5257) provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 8, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility 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 a nursing facility visit provided on June 8, 2023, 
by an out-of-network (OON) provider.
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 treating provider says an IRF admission is 
medically necessary and the care cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says The Plan says the requested IRF admission 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and congestive heart failure. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that you strongly feel that Eylea will provide a better 
response and decrease the amount of frequency the enrollee will need to receive injections. The Plan denied 
your request. The Plan says based on the lack of an indication for using Eylea in patients diagnosed with 
vitreous hemorrhage, right eye (H43.11), retinal neovascularization, unspecified, right eye (H35.051), 
puckering of macula, right eye (H35.371), atrophy of globe, left eye (H44.522) and vitreous degeneration, right 
eye (H43.811), the off-label denial is upheld under Part C. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our reviewer 
found that the elements of the coverage criteria are not satisfied. Our physician reviewer also found that the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D9970). 
 
You asked the Plan to pay for the dental service (D9970). You say that you are requesting reconsideration 
stating that the service was a standard service and should be covered. The Plan denied your request. The Plan 
says the service is not a covered benefit. 
 
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 dental 
service (D9970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D7210) on May 17, 2023. 
 
You asked the Plan to pay for the dental service (D7210). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 17, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental service (D7210) on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete dentures (D5110, D5120) provided on June 12, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed new dentures because your old ones 
were loose, and you were having trouble eating. 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 June 12, 2023. Therefore, 
we decided that the Plan does not have to pay for the complete dentures (D5110, D5120) provided on June 12, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical each additional x-ray (D0230 x 2) provided on 
July 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing 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 July 5, 2023. Therefore, 
we decided that the Plan does not have to pay for the periapical each additional x-ray (D0230 x 2) provided on 
July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D9910) on May 25, 2023. 
 
You asked the Plan to pay for the dental service (D9910). You say that you were unaware the service would not 
be covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 dental 
service (D9910) on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, an ophthalmic ultrasound, 
scanning computerized ophthalmic diagnostic imaging and gonioscopy provided on May 1, 2023. 
 
You asked the Plan to pay for the hospital outpatient clinic visit, an ophthalmic ultrasound, scanning 
computerized ophthalmic diagnostic imaging and gonioscopy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit, an ophthalmic ultrasound, 
scanning computerized ophthalmic diagnostic imaging and gonioscopy provided on May 1, 2023.