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

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 29, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was prescribed by the doctor prior to 
imaging, and you were not aware that it was not covered. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on March 29, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physical and occupational 
therapy to return to their prior level of function. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
and prefabricated post and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services in order to eat 
properly. The Plan denied your request. The Plan says these services are not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Core buildup, including any 
pins when required (D2950) and prefabricated post and core in addition to crown (D2954) are not covered 
under the Plans dental benefits. 
 
  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 core 
buildup, including any pins when required (D2950) and prefabricated post and core in addition to crown 
(D2954).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 26, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support the services. 
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 skilled nursing facility 
provided on January 26, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on March 25, 2023, to 
March 26, 2023. 
 You asked the Plan to pay for the subsequent hospital care. You say that the enrollee was no longer enrolled in 
hospice at the time 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided on March 25, 2023, to March 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been 
met. 
 
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 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that there was no time to provide additional 
information or to set up a peer-to-peer discussion. The Plan denied your request. The Plan says a lumbar 
epidural steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the LCD criteria has not been 
met as the enrollee has not achieved 50 % pain reduction for 3 months. Therefore, the request is not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve 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 July 8, 2019. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the arthrocentesis provided on February 16, 
2023. 
 
You asked the Plan to waive the deductible for the arthrocentesis. You say that you feel there is an error with 
the billed amount and allowed amount for this service. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient surgery. Your contract 
with the Plan also says that you must pay 2% coinsurance after meeting the deductible for outpatient surgery. 
 
You have only been asked to pay the billed amount towards the deductible, which is $199.80. The item or 
service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which 
applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the 
arthrocentesis was received on February 16, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the arthrocentesis provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), a comprehensive oral 
evaluation (D0150), and intraoral imaging (D0220), provided February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like you were given misinformation. 
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 D0330 was exhausted on date of service July 23, 2019, D0150 was exhausted on 
January 22, 2021, and D0220 was exhausted on February 14, 2023. Two intraoral images were taken on February 14, 2023. One intraoral image was approved and paid. The second intraoral image was denied. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330), a comprehensive 
oral evaluation (D0150), and intraoral imaging (D0220), provided February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on January 6, 2023. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you should have been eligible for partial 
reimbursement. The Plan denied your request. The Plan says the provider is not a part of the vendor network. 
 
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 obtained through a Plan network vendor.  
 
We looked at the file and the Plan's rules. The record shows this hearing aid was obtained by an out-of-network 
vendor. Based on this information, we decided that the Plan's rules for coverage of a hearing aid (V5298) have 
not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5298) provided on 
January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT cone beam, capture (D0364), and a diagnostic service 
consultation (D9310) on March 29, 2023. 
 
You asked the Plan to pay for D0364 and D9310. You say that you are having difficulty getting your dental 
work covered. The Plan denied your request. The Plan says the rendered dental services are not covered 
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 CT cone 
beam, capture (D0364), and a diagnostic service consultation (D9310) on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5211). 
 
You asked the Plan to pre-approve 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 January 19, 2023. 
Therefore, we decided that the Plan does not have to pre-approve partial upper denture (D5211).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 01, 2023. 
 
You asked the Plan to pay for home visit. 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 home visit provided on 
March 01, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services (codes 99454, 99457, and 
99458) provided on February 28, 2022. 
 
You asked the Plan to pay for the remote monitoring services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says with the information provided, it cannot be 
determined how the enrollee came to the servicing provider or whether the services were medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the remote monitoring services have 
been met. Medical records were not provided for this case. The record shows that the Plan made multiple 
attempts to obtain this information, but it was not received. Without medical records we are unable to 
determine if the criteria for coverage were met. Therefore, we decided that the Plan does not have to pay for the 
remote monitoring services (codes 99454, 99457, and 99458) provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) purchased on February 18, 2023. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you request for the Plan to add this vendor 
to their vendor list, as it is very important to you and your family. The Plan denied your request. The Plan says 
hearing aids are not covered if the services are not registered in advance. The Plan contract also says that 
hearing aids ordered through providers other than the Plan hearing vendors 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 obtained through a Plan hearing vendor.  
 
 
  We looked at the file, and the Plan's rules. The record shows this hearing aid was obtained through an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of a hearing aid 
(V5298) have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5298) 
purchased on February 18, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the physical therapy visit provided on 
February 6, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the physical therapy visit by an OON provider. You say that 
you do not agree with the denial for reimbursement of payment made for physical therapy. The Plan denied 
your request. The Plan says the service could have been provided by an in-network provider. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to provide reimbursement for the physical therapy visit 
provided on February 6, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204). provided on February 23, 2023. 
 
You asked the Plan to pay for an office visit (99204).. 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 an office visit (99204). 
provided on February 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic lumbar back 
pain and recently underwent radiofrequency ablation (RFA). The record does not document that the treatment 
has failed or that there are red flag signs or symptoms, or abnormal neurological findings. The records do not 
support that the MRI is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic walking boot provided on December 27, 2022. 
 You asked the Plan to pay for the walking boot. You say that the equipment provided was not related to the 
enrollee's hospice diagnosis. 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 a pneumatic walking boot provided on December 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on March 27, 2023. 
 You asked the Plan to pay for the wound care supplies. You say that the supplies were ordered by the enrollee's 
doctor. 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 wound care supplies provided on March 27, 2023.