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

 
We decided that the Plan does not have to pre-approve 90 additional trips for routine transportation. 
 
You asked the Plan to pre-approve 90 additional trips for routine transportation. You say that you have to go to 
a facility once a day for treatment. The Plan denied your request. The Plan says you have exceeded your benefit 
limit.  
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 84 one-way 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 90 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on March 15, 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 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 pay for an 
endosteal implant (D6010) provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation and intraoral x-ray 
(D0210, D0150) provided on June 5, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 a comprehensive oral evaluation and 
intraoral x-ray (D0210, D0150) provided on June 5, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the office visit provided on May 3, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on May 08, 2023. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration for the services 
provided. 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 injections provided on 
May 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010) for 
teeth 11, 13, and 14, bone grafts at the time of implant (D6104) for teeth 11 and 12, custom abutments (D6057) 
for teeth number 11, 13, and 14, implant supported porcelain fused to metal crown (D6066) for teeth 11, 13, 
and 14, soft tissue graft for tooth 11, and prosthodontics (D6245) for tooth number 12. 
 
  You asked the Plan to pre-approve the surgical placement of an implant body (D6010) for teeth 11, 13, and 14, 
bone grafts at the time of implant (D6104) for teeth 11 and 12, custom abutments (D6057) for teeth number 11, 
13, and 14, implant supported porcelain fused to metal crown (D6066) for teeth 11, 13, and 14, soft tissue graft 
for tooth 11, and prosthodontics (D6245) for tooth number 12. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not covered in your dental 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 pre-approve the 
surgical placement of an implant body (D6010) for teeth 11, 13, and 14, bone grafts at the time of implant 
(D6104) for teeth 11 and 12, custom abutments (D6057) for teeth number 11, 13, and 14, implant supported 
porcelain fused to metal crown (D6066) for teeth 11, 13, and 14, soft tissue graft for tooth 11, and 
prosthodontics (D6245) for tooth number 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for detailed and extensive oral evaluation - problem focused, by 
report (D0160), and reline custom sleep apnea appliance (indirect) (D9953) provided on June 6, 2023, and June 
14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had this sleep apnea device made because 
you could not use the continuous positive airway pressure (CPAP) machine. You also say that you feel this 
should be covered under medial and not dental. The Plan denied your request. The Plan says these services are 
excluded from coverage under your plan. The Plan also says that if a claim is submitted with code E0486, the 
appliance would be paid under the medical benefit. 
 
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 detailed and extensive oral evaluation - problem 
focused, by report (D0160), and reline custom sleep apnea appliance (indirect) (D9953) provided on June 6, 
2023, and June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of skin and tissue and a prefabricated walking 
boot provided on August 8, 2022, August 16, 2022, and August 23, 2022, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the removal of skin and tissue and a prefabricated walking boot. You say that 
you were surprised that the claims were not paid, and you would like the primary care physician to do a retro 
referral. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved authorization. Also, the services rendered were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The 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 the removal of skin and tissue and a prefabricated 
walking boot provided on August 8, 2022, August 16, 2022, and August 23, 2022, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of an upper extremity 
joint provided on May 14, 2023. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI) of an upper extremity joint. You say that 
records have been provided to show medical necessity. 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 the magnetic resonance 
imaging (MRI) of an upper extremity joint provided on May 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on June 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility care visit. You say that you were unaware a prior authorization 
was required. The Plan denied your request. The Plan says an authorization was not obtained prior to the 
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 care visit provided on June 28, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3020) provided on April 2, 2023. 
 
You asked the Plan to pay for the foot orthotics. You say that your plan covers unlimited custom orthotics. You 
also say that you have previously had them made and were covered with a $10 copayment. The Plan denied 
your request. The Plan says you must go to a supplier that is enrolled with Medicare for Medicare to pay for 
your device. 
 
The Plan must follow Medicare rules. Medicare rules say a provider or supplier must be enrolled in the 
Medicare program to receive payment for covered items or services. 
 
We looked at the file and Medicare rules. The provider is not enrolled in Medicare so is not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of the foot orthotics have not 
been met. Therefore, we decided that the Plan does not have to pay for the foot orthotics (L3020) provided on 
April 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305-26 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 88305-26. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 13, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 88305-26 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88305-26 billed for date of service 
June 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve 3 home health physical therapy visits. You say that you would like to 
request reconsideration of the denied home health physical therapy visits and that the services requested are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that all appropriate home health PT goals have been met. There is no documentation to 
show why the professional skill of a physical therapist would be further required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2023, billed with 
multiple codes including 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
May 10, 2023, billed with multiple codes including 81433.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular overdenture  
(D5865/D5863). 
 
You asked the Plan to pre-approve the dental services. You say that you believe this should be covered. 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 February 23, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary and mandibular overdenture 
(D5865/D5863).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection wheelchair seat cushion, adjustable, 
width less than 22 inches, any depth (E2622). 
 
You asked the Plan to pre-approve a skin protection wheelchair seat cushion. You say that there are 
modifications that are needed to continue to meet the enrollee's medical needs. The Plan denied your request. 
The Plan says the requested accessory does not meet the coverage criteria. 
 
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 skin protection wheelchair seat cushion. 
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 a diagnosis of chronic obstructive pulmonary disease 
(COPD), obesity and diabetes. He is non-ambulatory. Per L33312 and A52505, the enrollee does not have a 
qualifying diagnosis listed in group 1 or 2 of A52505. He has intact skin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin protection wheelchair seat cushion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skin protection wheelchair seat cushion, adjustable, width 
less than 22 inches, any depth (E2622).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture complete mandibular (D5865) and a 
bone graft at time of implant (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says this requested services have been correctly denied. 
 
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 a denture was exhausted on date of service April 24, 2023. This benefit does not include 
D6104. Therefore, we decided that the Plan does not have to pre-approve an overdenture complete mandibular 
(D5865) and a bone graft at time of implant (D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics and a power standing feature. 
 
You asked the Plan to pre-approve upgraded electronics and a power standing feature. You say that the enrollee 
does not reside in a nursing home or skilled nursing facility. You also say that the enrollee resides at home. The 
Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the 
enrollee to control the power options with their own switches. The Plan also says a power standing system 
serves no medical purpose and cannot be covered.   

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 upgraded electronics. Our reviewer says 
that the requested upgraded electronics are not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee is non-ambulatory. The documentation indicates the enrollee is able to 
perform meal preparation. The reviewer found that the enrollee has sufficient strength and function in upper 
extremities to manage standard power drives. Therefore, the reviewer found that the request for upgraded 
electronics are not medically reasonable or 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 upgraded electronics have not been met. Additionally, a power standing feature 
is not covered as it is not medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
upgraded electronics and a power standing feature.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from April 
23, 2023, to May 16, 2023. 
 
You asked the Plan to pay for the SNF stay. You say that the services should be covered under the Medicare 
act. The Plan denied your request. The Plan says the enrollee exhausted their 100-day SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 29, 
2022, to July 24, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.  Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided 
from April 23, 2023, to May 16, 2023.