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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
5, 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 July 14, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth guard (D9944). 
 
You asked the Plan to pre-approve the dental service. You say that the mouth guard would help you with your 
teeth grinding. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the mouth guard 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 pre-approve a 
mouth guard (D9944).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is now bed bound and unable to walk. 
You also say the enrollee has previously tolerated therapy provided at an IRF and was able to complete the 3 
hours of therapy required. You would like reconsideration of this denial. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for admission to an IRF.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 3, 2023 to April 6, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Home Health services, HHAs must submit 
HH PPS claims with a type of bill with the 4th digit of 9. 
 
We looked at the file and Medicare rules. The claim was submitted with a type of bill of 0323. The fourth digit 
must be "9". Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided on April 3, 2023 to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (97597) provided on November 25, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97597 is not supported in the medical record. Specifically, the billed code is included in 
the consolidated SNF payment issued under claim number 820223390429152. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (97597) provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that the injection is a very safe and 
effective treatment for the enrollee and can help them return to work more quickly The Plan denied your 
request. The Plan says a platelet rich plasma injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are not covered.  
 
We looked at the file and Medicare rules. The record shows the injection was requested to treat a 
musculoskeletal injury. Based on this information, we decided that Medicare rules for coverage of a platelet 
rich plasma injection. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
platelet rich plasma injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on April 8, 
2021. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that that your physician 
provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan 
says the claim was received untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a claim for the subsequent nursing facility care services was not filed until March 2, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care services 
provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the socket replacement (L5701) provided on March 9, 2023. 
 
You asked the Plan to pay for the socket replacement (L5701). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have been met. In this case, the reasonableness and medical necessity of the socket 
replacement (L5701) in question is amply documented by the physicians notes in this file, in a way that 
complies with all relevant durable medical equipment (DME) regulations by Medicare. The records amply 
support that the item was medically necessary. There was proper documentation of the necessity of the item, 
and there was a valid prescription/order for the item. Therefore, we decided that the Plan has to pay for the 
socket replacement (L5701) provided on March 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 pre-approve dental visit with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you were referred to this provider and 
would like to see him. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental visit 
with an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 12, 2022. 
 You asked the Plan to pay for the office visit. You say that the enrollee was not enrolled in hospice on the date 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on December 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility physician services provided on July 
14, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the skilled nursing facility physician services. You say that the services were 
provided in good faith to the enrollee. The Plan denied your request. The Plan says the services provided were 
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 skilled nursing facility physician services provided 
on July 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts at the time of implant placement  
(D6104 x 2), alveoloplasties not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant 
(D7321 x 2), and the surgical placement of an implant body: endosteal implants (D6010 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental 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. 
 
 
  
 
 
 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, dental services are not covered under this benefit when received from an out-of-
network provider. Therefore, we decided that the Plan does not have to pre-approve bone grafts at the time of 
implant placement (D6104 x 2), alveoloplasties not in conjunction with extractions-one to three teeth or tooth 
spaces, per quadrant (D7321 x 2), and the surgical placement of an implant body: endosteal implants  
(D6010 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from January 27, 
2023, to February 2, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you feel mislead because you were 
told by the case worker that there would be no charge and you cannot afford to pay the bill. 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 $175 
copayment per day for days 1 to 6 and $0 copayment after day 6 for inpatient hospital care services.  
 
 You have been asked to pay a $1,050 copayment an IRF stay ($175 per day x 6 days = $1,050). This 
item/service falls within the for inpatient hospital care services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an IRF stay provided from January 27, 2023, to February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. Based 
on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on January 04, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were not 
aware you had to pay an additional copayment for the MRI. 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 $225 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $225 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 total you owe is $204.98, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on January 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) and reconstruction of mandible or maxilla, endosteal implant (21248). 
 
You asked the Plan to pre-approve the implants. You say that the enrollee has a history of tonsil cancer and had 
chemotherapy and radiation to the head resulting in loss of teeth. You say implants are necessary to help with 
speaking and eating. The Plan denied your request. The Plan says the services are purely dental in nature and 
cannot be covered under the medical plan. The Plan also says with regards to the enhanced dental benefit, the 
enrollee has utilized 100% of the allowance for the calendar year. 
 
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 enrollee has exhausted their $2,000 annual maximum dental benefit. The requested services are also 
not eligible for coverage under the medical benefit. Therefore, we decided that the Plan does not have to pre-
approve surgical placement of implant body: endosteal implant (D6010) and reconstruction of mandible or 
maxilla, endosteal implant (21248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), sphere lenses (V2100), lenses (V2783), 
photochromatic lenses (V2744) and ant-reflective coating (V2750) provided on March 10, 2023. 
 
You asked the Plan to pay for frames (V2020), sphere lenses (V2100), lenses (V2783), photochromatic lenses 
(V2744) and ant-reflective coating (V2750). You say that you were not aware that you could not send in both 
your eyeglasses and contacts. The Plan denied your request. The Plan says this exceeds the maximum benefit 
per period. The Plan also says that the patient is responsible for this purchase in its entirety.  
 
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 these services when one pair of standard lenses and frames every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every year. The record shows this benefit was exhausted on March 10, 2023. Based on this information, 
we decided that the Plan's rules for coverage of frames (V2020), sphere lenses (V2100), lenses (V2783), 
photochromatic lenses (V2744) and ant-reflective coating (V2750) have not been met. Therefore, we decided 
that the Plan does not have to pay for frames (V2020), sphere lenses (V2100), lenses (V2783), photochromatic 
lenses (V2744) and ant-reflective coating (V2750) provided on March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam computed tomography (CT) scan and 
consultation provided on December 19, 2022. 
 
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 cone 
beam computed tomography (CT) scan and consultation provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5225) provided on April 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that your denture needed to be replaced and you 
were unaware this was not a covered benefit. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental 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 
maxillary partial denture (D5225) provided on April 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is 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 you are noted 
to be able to follow-up in outpatient clinic regarding your transtibial amputation, which is healing and ready to 
be fit with a prosthesis. You do not require continued skilled nursing care for wound care. You will also need 
physical therapy for prosthetic training once you receive your prosthesis and therefore, you do not require 
home health physical therapy at this time. 
 
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 skilled nursing services (G0299).