Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 15, 2022, 
through November 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was sent to the emergency department (ED) on October 15, 2022, from a group home 
where he was recently placed. He was reported as "combative" and caregivers were no longer able to care for 
him. There were no acute medical complaints. His past medical history was remarkable for dementia. He was 
initially placed in an observation status and changed to an inpatient status on October 17, 2022 while awaiting 
further planning for long-term placement. The ED Observation Discharge Summary documented: 
Currently pending safe discharge planning. This morning patient has no acute complaints. Given difficulty 
with discharge planning and presumed prolonged length of stay he will be hospitalized for ongoing 
management. The review has determined that the record showed that at the time of the inpatient admission the 
admitting physician reasonably expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 15, 2022, through November 1, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroscopy with chondroplasty to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an outpatient surgery. You say that you are requesting these services to be 
provided by an out-of-network provider. The Plan denied your request. The Plan says this surgery will be 
approved if provided by a participating physician. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a left knee arthroscopy with chondroplasty to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014), a visual field 
examination (92083) and ophthalmic diagnostic imaging (92134) provided on March 07, 2023. 
 
You asked the Plan to pay for a medical eye examination (92014), a visual field examination (92083) and 
ophthalmic diagnostic imaging (92134). You say that you are appealing with supporting records. 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 medical eye 
examination (92014), a visual field examination (92083) and ophthalmic diagnostic imaging (92134) provided 
on March 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) for teeth number 11 and 13 (D6011 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 your benefit for the requested services has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services has already been exhausted.  
  
 
 
Specifically, the Plans contract states that up to two dental implants are covered per year. The Plan previously 
authorized dental implants for teeth number 7 and 9. Therefore, you have exhausted the allowable benefit for 
the dental services requested in this case. Therefore, we decided that the Plan does not have to pre-approve 
surgical access to an implant body (second stage implant surgery) for teeth number 11 and 13 (D6011 x 2).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5225). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your benefit for the requested item has already 
been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item was previously exhausted. 
Therefore, we decided that the Plan has to pre-approve an upper partial denture (D5225).  
 
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 biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265 x 4). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on April 7, 2023. 
 
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that while the Plans statement shows no copayment for you, the provider has invoiced you 
for the $19.88 discount for the determination of refractive state (92015). You also say that this was an annual 
eye examination and was improperly coded by the provider and should have no copayment. The Plan denied 
your request. The Plan says the services rendered to the member were not scheduled as a routine eye 
examination. The Plan also says that according to conversations with the office, you were informed that 
refractions are not covered by health insurance. 
 
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 eye examinations and eye refractions were a part of a routine 
examination. 
 
We looked at the file and the Plan's rules. The Plan rules say you pay $15 for each Medicare-covered 
examination (diagnosis and treatment for diseases and conditions of the eye). The Plan contract also says that 
Original Medicare does not cover routine eye examinations (eye refractions) for eyeglasses/contacts. The 
record shows that these services were diagnostic/medical and not routine. Based on this information, we 
decided that the Plan's rules for coverage of a medical eye examination (92014) and a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
medical eye examination (92014) and a determination of refractive state (92015) provided on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete mandibular denture (D5751) provided on 
March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that 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 March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for reline complete mandibular denture (D5751) 
provided on March 7, 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 
tooth #27 (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body. 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 surgical placement of implant 
body: endosteal implant is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve surgical placement of implant body: endosteal implant tooth #27 (D6010).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97140, 97530) provided on September 15, 
2022. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with valid diagnosis codes. 
 
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 codes 97140 and 97530 are not supported in the medical record. Specifically, diagnosis 
codes M62.81 and M79.18 have an exclude note and should not be billed together. Based on this information, 
we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for therapy services (97140, 97530) provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 22, 2023, to February 
28, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for dental services provided on February 22, 2023, to February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 7, 2023, to February 
11, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on February 7, 2023, to February 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on March 4, 2023. 
 
You asked the Plan to pay for the compression stockings. The Plan denied your request. The Plan says this 
service is not covered by your Plan or Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 pay for the compression 
stockings identified with code A6533 that were issued on March 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital, binaural hearing aids (V5261), dispensing fee 
(V5160), and an ear mold (V5265) provided on December 19, 2022. 
 
You asked the Plan to pay for digital, binaural hearing aids (V5261), dispensing fee (V5160), and an ear mold 
(V5265). You say that you did not understand the ordering process for hearing aids and likely misunderstood 
the order options and instructions. The Plan denied your request. The Plan says the hearing benefit is not 
covered if the services are not registered in advance. 
 
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 they are purchased by a Plan hearing specific provider.  
 
   
We looked at the file and the Plan's rules. The Plan rules say that hearing aids ordered through providers other 
than Plan hearing specific providers are not covered. The record shows that these services/materials were 
received out-of-network. Based on this information, we decided that the Plan's rules for coverage of digital, 
binaural hearing aids (V5261), dispensing fee (V5160), and an ear mold (V5265) have not been met. Therefore, 
we decided that the Plan does not have to pay for digital, binaural hearing aids (V5261), dispensing fee 
(V5160), and an ear mold (V5265) provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on April 18, 
2023. 
 
You asked the Plan to pay for periodontal maintenance. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 
periodontal maintenance (D4910) provided on April 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on April 24, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on April 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 17, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service provided on April 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that you do not agree with the denial of payment for 
the dental service received. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for the dental service provided on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and surgical extractions (D7210) 
provided on March 23, 2023. 
 
You asked the Plan to pay for a consultation and surgical extractions. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
consultation (D9310) and surgical extractions (D7210) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic service provided on February 7, 2023. 
 
You asked the Plan to pay for a chiropractic service. You say that it is medically necessary. The Plan denied 
your request. The Plan says manual manipulation of the spine to correct a subluxation is covered. Services 
other than "Medicare-covered" chiropractic services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic service provided on February 7, 2023.