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

 
We decided that the Plan does not have to pre-approve  push handles (K0108 x2), Ram Mount cup holder 
(K0108), attendant control (E2331), custom fabricated wheelchair back cushion (E2617), and custom 
fabricated wheelchair seat cushion (E2609). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that  the enrollee needs a 
new power wheelchair to be able to be safe. You also say that you would like payment to be approved for this 
necessity. The Plan denied your request. The Plan says the push handles and cup holder do not serve a medical 
need and cannot be covered. Per Medicare rules, an attendant control cannot be covered in addition to a 
beneficiary-operated joystick. The notes do not clearly explain why a positioning back cushion not sufficient to 
meet the member's needs, as required by Medicare guidelines. The Plan also says that the notes do not show 
that a skin protection cushion, positioning cushion or skin protection and positioning cushion cannot be used. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate strength to manage power drives. The 
attendant control and push handles are not medically necessary. Per A52504 as the cup is not medically 
necessary and the medical necessity for custom cushions compared to standard is not 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 the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  push handles (K0108 x2), Ram Mount cup holder (K0108), 
attendant control (E2331), custom fabricated wheelchair back cushion (E2617), and custom fabricated 
wheelchair seat cushion (E2609).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on June 6, 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 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 September 14, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on June 6, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the patient is using and are 
benefiting from BiPAP treatment. You say that you recommend the patient go home with a ventilator as 
opposed to a BiPAP machine as their health will greatly benefit from it. The Plan denied your request. The Plan 
says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the patient 
has kyphosis and metastatic with resultant thoracic restrictive disease and chronic respiratory failure. The 
patient has documentation that supports improvement with a BiPAP as the carbon dioxide was reduced 
appropriately. Also, the patient does not have documentation to support failure with a BiPAP or BiPAP with 
AVAPS. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
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 it is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.

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 do not require an acute rehab 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, at an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening  hard tissue (D4249), biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265), guided tissue regeneration - 
resorbable barrier, per site (D4266), consultation - diagnostic service provided by dentist or physician other 
than requesting dentist or physician (D9310), and bone replacement graft for ridge preservation - per site 
(D7953) provided on May 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that your plan is a preferred provider organization 
(PPO) and you should be able to see any provider. You also say that you would like to know if there is another 
way to reduce the massive cost of your dental work. The Plan denied your request. The Plan says these services 
are not a covered expense 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for clinical crown 
lengthening  hard tissue (D4249), biologic materials to aid in soft and osseous tissue regeneration, per site 
(D4265), guided tissue regeneration - resorbable barrier, per site (D4266), consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310), and bone replacement graft 
for ridge preservation - per site (D7953) provided on May 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481) provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87481) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) for tooth #13 provided on May 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went for a root canal, but the dentist put on a 
crown, and you thought it was covered. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the specific crown is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2750) for tooth #13 provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4197, B4224 and B4220 billed for date of 
service April 7, 2023. 
 
You asked the Plan to pay for procedure codes B4197, B4224 and B4220. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says the records 
provided do not include a physician order for these services. 
 
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 procedure codes B4197, B4224 and 
B4220 have been met for the date in question. Specifically, there is no order for services on April 7, 2023. The 
order notes that, "delivery last through April 6, 2023". Therefore, the services at issue cannot be verified. 
Therefore, we decided that the Plan does not have to pay for procedure codes B4197, B4224 and B4220 billed 
for date of service April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 6) and bone replacement 
grafts for ridge preservation (D7953 x 6). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat properly and require these 
implant procedures. The Plan denied your request. The Plan says these services are not covered under the Plan's 
dental 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 pre-approve 
endosteal implants (D6010 x 6) and bone replacement grafts for ridge preservation (D7953 x 6).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve the personal care services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
are excluded from your plan benefits. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May 
11, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you were trying to save the 
tooth you were having pain in and it is the only tooth left to hold the partial. You also say that you did not 
know that there is 36 month limitation between panoramic x-rays. 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 Jun 27, 2022. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3000) purchased on 
February 28, 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 a covered 
benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics 
(L3000) purchased on February 28, 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 enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a LTACH. 
 
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 the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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 frames (V2020), tinting (V2745), anti-reflective coating 
(V2750), progressive lens (V2781) and polycarbonate (V2784) provided on May 9, 2023. 
 
You asked the Plan to pay for frames (V2020), tinting (V2745), anti-reflective coating (V2750), progressive 
lens (V2781) and polycarbonate (V2784). You say that you are appealing this claim. The Plan denied your 
request. The Plan says the services are covered benefits, but you have exceeded the limits set in the EOC.  
 
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 up to $200 toward your purchase of frames (with standard lenses covered in full). 
 
We looked at the file and the Plan's rules. The Plan rules say they pay up to $200 toward your purchase of 
frames (with standard lenses covered in full). The Plan rules also say they cover one pair of standard lenses and 
frames every two years. The record shows this benefit has been exhausted on date of service November 22, 
2022. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), tinting 
(V2745), anti-reflective coating (V2750), progressive lens (V2781) and polycarbonate (V2784) have not been 
met. Therefore, we decided that the Plan does not have to pay for frames (V2020), tinting (V2745), anti-
reflective coating (V2750), progressive lens (V2781) and polycarbonate (V2784) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104), and 
surgical placement of implant body: endosteal implant (D6010), provided on September 26, 2022. 
 
You asked the Plan to pay for the bone graft  and surgical placement of implant body. You say that you are 
requesting a review and have submitted the supplemental document outlining your treatment plan. The Plan 
denied your request. The Plan says if a service is not listed in the medical benefits chart, it is not covered. 
 
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 bone 
graft at time of implant placement (D6104), and surgical placement of implant body: endosteal implant 
(D6010), provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an extraction (D7140) 
for tooth #31 provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentist referred you for a tooth extraction 
and it was an emergency situation. The Plan denied your request. The Plan says your annual dental maximum 
benefit for the year 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 $400 for dental services on January 17, 2023. On January 23, 2023, the Plan paid $588 for 
dental services. On March 15, 2023, the Plan paid $130 for dental services. On April 26, 2023, the Plan paid 
$162 for dental services. On May 1, 2023, the Plan paid $145 for dental services. On May 17, 2023, which was 
processed prior to the May 15, 2023, claim the Plan paid $407 for dental services. On June 12, 2023, which 
was processed prior to the Mary 15, 2023, claim the Plan paid $168. For the year of 2023 the Plan paid $2,000 
($400 paid + $588 paid + $130 paid + $162 paid + $145 paid + $407 paid + $168 paid) for dental services; 
therefore your annual dental benefit for the year of 2023 was exhausted on the date of service of June 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an 
extraction (D7140) for tooth #31 provided on May 15, 2023.