Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 02, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are requesting reconsideration 
for the denied claim. 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 provided on August 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), the periodontal 
scaling and root planing (D4341) on all 4 quadrants, the gingival irrigation (D4921) for all 4 quadrants, the 
surgical removal of erupted tooth (D7210) for tooth #12, and medicaments (D9630) provided on August 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you thought the Plan would pay for the dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the adjunctive pre-diagnostic test, the periodontal scaling and root planing, the gingival irrigation, the 
surgical removal of erupted tooth, and medicaments are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431), the periodontal scaling and root planing (D4341) on all 4 quadrants, the 
gingival irrigation (D4921) for all 4 quadrants, the surgical removal of erupted tooth (D7210) for tooth #12, 
and medicaments (D9630) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 28, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration provided on July 20, 2023. 
 
You asked the Plan to pay for chemotherapy administration. You say that you are requesting reconsideration 
for the denied claim. 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 chemotherapy 
administration provided on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic images (D0230 x 2), limited oral evaluation-problem focused 
(D0140), interim partial denture (D5821), extractions, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210 x 2), and the bone replacement grafts for ridge preservation-per site (D7953 x 2) 
provided from March 7, 2023, through April 4, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental items/services provided are 
not covered by Medicare or the Plan.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  
The items/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 items/services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic images 
(D0230 x 2), limited oral evaluation-problem focused (D0140), interim partial denture (D5821), extractions, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2), and the bone replacement 
grafts for ridge preservation-per site (D7953 x 2) provided from March 7, 2023, through April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 07, 2023. 
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for the 
denied claim. 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 physician services 
provided on August 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown for tooth #30 (D6752) provided on May 17, 
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 the appealed claim with date of service 
May 17, 2023. Therefore, we decided that the Plan does not have to pay for a retainer crown for tooth #30 
(D6752) provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 25, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. 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 the Plan paid for a panoramic radiographic image (D0330) on May 11, 2021; therefore, your benefit for 
the requested item or service was exhausted on the date of service of May 11, 2021. Therefore, we decided that 
the Plan does not have to pay for a panoramic radiographic image (D0330) provided on August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you read that Medicare will cover custom 
orthotics based upon the need and they are medically necessary for your medical condition. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
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 pre-approve foot orthotics.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission.  
 
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 enrollee has ongoing acute medical issues and still requires acute care services. 
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 the enrollee is not currently receiving but that would be 
available at the LTACH facility.  The elements of the coverage rules are not satisfied.  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 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 pre-approve bone replacement grafts and biologic materials to aid in 
soft and osseous tissue regeneration (D4263, D4264, D4265, D6106). 
 
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 the services denied correctly as they do 
not fall within your 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 bone 
replacement grafts and biologic materials to aid in soft and osseous tissue regeneration (D4263, D4264, D4265, 
D6106).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on August 8, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you went to the Plan's website and requested 
information on a provider in your network for an audiologist and hearing aids. You also say that the website 
directed you to this provider without any exception to service. The Plan denied your request. The Plan says the 
hearing benefit is not covered if the services are not registered in advance. The Plan also says that hearing aids 
ordered through providers other than the Plan hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are provided through an in-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5261) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on September 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had no idea about waiting 36 months for the 
x-rays and the provider should had advised you. 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 the Plan paid for the intraoral complete series of radiographic images (D0210) on October 25, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of October 25, 
2022. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on September 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to crown (D6058) for tooth #3 provided on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you called for approval it was denied but 
you were told that a crown replacement would be covered. The Plan denied your request. The Plan says the 
denial of payment for these services is correct because the implant and all related services are not covered by 
the Plan. Also, it was verified that you did not contact the Plan prior to the date of service to verify benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057) and an abutment supported to crown (D6058) for tooth #3 provided on May 31, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 17, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D2950), 
and core buildup (D2950) for tooth #4 provided outside of the United States on May 26, 2023, and June 7, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were an emergency, and you 
did not know any dentist in Arizona that would do the dental procedures. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the Plan only covers emergency and 
urgent services when received outside the United States. 
 
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 only 
covered under this benefit when provided by a licensed dental provider in the United States. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D2950), and 
core buildup (D2950) for tooth #4 provided outside of the United States on May 26, 2023, and June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on  
July 27, 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 the hearing aids in this case are 
not payable as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for extracapsular cataract removal with 
insertion of intraocular lens prosthesis (66984) provided from August 9, 2023, to August 11, 2023. 
 
You asked the Plan to waive the copayment for extracapsular cataract removal with insertion of intraocular lens 
prosthesis (66984). You say that when reading the information with the flex card, it clearly states that you can 
use this card for out-of-pocket cost for dental, vision, and hearing services. You also say it does not exclude 
surgery on this information. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.   
You have been asked to pay a $250 copayment for extracapsular cataract removal with insertion of intraocular 
lens prosthesis (66984). This item/service falls within the outpatient surgery and/or services at an ambulatory 
surgical center or outpatient hospital facility 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. The record shows that this was a medical service not a supplemental vision 
service. Therefore, we decided that the Plan does not have to waive the copayment for extracapsular cataract 
removal with insertion of intraocular lens prosthesis (66984) provided from August 9, 2023, to August 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on April 21, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided the medical 
records for the claim to be paid. The Plan denied your request. The Plan says the documentation requirements 
have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. There is no information on the proof of delivery to tie it 
to the packing slip to verify what was delivered to the enrollee. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the supply allowance for a continuous glucose monitor (CGM) provided by an out-of-network 
provider on April 21, 2023.