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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 01, 2023, 
to May 15, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on May 01, 2023, to May 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided from March 14, 2023, to March 
15, 2023. 
 
You asked the Plan pay for the SNF services. You say that the dates of service which the enrollee required and 
received during the period in question are coverable. The Plan denied your request. The Plan says the enrollee's 
100-day SNF benefit was exhausted. 
 
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 November 8, 
2022, to March 17, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may have still needed 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 pay for the SNF services provided from March 14, 2023, to March 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation provided on May 05, 2023. 
 
You asked the Plan to pay for a telehealth consultation. You say that the enrollee was in a nursing home at the 
time the service was rendered. 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 telehealth consultation 
provided on May 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on June 12, 
2023. 
 
You asked the Plan to pay for remote patient monitoring services. You say that these services were medically 
necessary. 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 remote patient 
monitoring services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on July 31, 2023. 
 
You asked the Plan to pay for chronic care management. You say that the services were medically necessary. 
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 chronic care 
management provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 03, 2023, 
to May 04, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on May 03, 2023, to May 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation for teeth 
#4, 5, and 6 (D7953 x3). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation for teeth #4, 5, and 6. You say 
that the services are necessary. The Plan denied your request. The Plan says the requested services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation for teeth #4, 5, and 6 (D7953 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve presbyopia-correct function (V2788). 
 
You asked the Plan to pre-approve presbyopia-correct function (V2788). You say that the upgraded lens will 
improve your vision for everyday tasks and life. The Plan denied your request. The Plan says the criterion has 
not been met for this request. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL. 
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve presbyopia-correct 
function (V2788).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
April 4, 2023. 
 You asked the Plan to pay for initial hospital inpatient or observation care. You say that the claim should be 
reprocessed for payment. 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 initial hospital inpatient or observation care provided on April 
4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve IRF services. You say that the facility is better for your treatments. The Plan 
denied your request. The Plan says these services can be provided to you 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 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 
inpatient rehabilitation facility (IRF) services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the intraoral 
complete series of radiographic images (D0210), and the adjunctive pre-diagnostic test (D0431) provided on 
June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you required dental work to be completed due 
to a broken tooth. The Plan denied your request. The Plan says your benefit for the comprehensive oral 
evaluation and the intraoral complete series of radiographic images has already been exhausted. Also, the 
adjunctive pre-diagnostic test 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, certain limitations apply. The record 
shows the Plan paid for a comprehensive oral evaluation (D0150) and the intraoral complete series of 
radiographic images (D0210) on June 15, 2021; therefore, your benefit for the requested items or services was 
exhausted on the date of service of June 15, 2021. The requested adjunctive pre-diagnostic test is not covered 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150), the intraoral complete series of radiographic images (D0210), and the adjunctive pre-
diagnostic test (D0431) provided on June 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 20, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the documents attach support 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 physical therapy 
provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 26, 
2023. 
 
You asked the Plan to pay for the periodontal maintenance. You say that would like the plan to review and 
reconsider the denial. The Plan denied your request. The Plan says this service 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on August 10, 
2023. 
 
You asked the Plan to pay for the dental service. You say that your last cleaning was in February, and you are 
allowed 2 routine cleaning per year. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a periodic oral evaluation (D0120) on February 2, 2023, and paid for a limited oral 
evaluation (D0140) on February 9, 2023; therefore, your benefit for the requested item or service was 
exhausted on the date of service of February 9, 2023. Therefore, we decided that the Plan does not have to pay 
for a periodic oral evaluation (D0120) provided on August 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on May 25, 2023, to June 
14, 2023. 
 
You asked the Plan to pay for physical therapy visits. You say that an authorization was not made because you 
thought there were still visits remaining. 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 physical therapy visits 
provided on May 25, 2023, to June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 22, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the services were medically 
necessary. 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 domiciliary or rest home 
visit provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555, 
C1778). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational therapy. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555, C1778).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), a 2D photographic images (D0350), a cone beam 
(D0367), a cleaning (D1110), fluoride treatment (D1206), toothbrush instructions (D1330), a resin-based 
composite (D2330 and D2391) for tooth #20 and #24, gingival irrigation (D4921), an unspecified periodontal 
procedure (D4999), and medicaments (D9630) provided by an out-of-network provider on July 17, 2023. 
 You asked the Plan to pay for the dental services. You say that you called the Plan and you were told the 
provider was in-network. 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. Also, it was verified that you 
were told the provider was out-of-network and you were referred to the online member portal to find an in-
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. 
 
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 a comprehensive oral evaluation (D0150), the intraoral radiographic images (D0220 and D0230), 
bitewings (D0274), a 2D photographic images (D0350), a cone beam (D0367), a cleaning (D1110), fluoride 
treatment (D1206), toothbrush instructions (D1330), a resin-based composite (D2330 and D2391) for tooth #20 
and #24, gingival irrigation (D4921), an unspecified periodontal procedure (D4999), and medicaments (D9630) 
provided by an out-of-network provider on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and the core buildup (D2950) for tooth #18 
provided on June 1, 2023, and June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary for you to get the 
retreatment of the root canal done and you would like to be reimbursed. The Plan denied your request. The Plan 
says your annual dental maximum benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $1,150.40 for dental services on January 5, 2023. On January 27, 2023, the Plan paid 
$218.58 for dental services. On March 2, 2023, the Plan paid $172.08 for dental services. On March 8, 2023, 
the Plan paid $458.94 for dental services. On April 11, 2023, the Plan paid $191 for dental services. For the 
year of 2023 the Plan paid $2,191 ($1,150.40 paid + $218.58 paid + $172.08 paid + $458.94 paid + $191 paid) 
for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the 
date of service of April 11, 2023. Therefore, we decided that the Plan does not have to pay for a crown (D2740) 
and the core buildup (D2950) for tooth #18 provided on June 1, 2023, and June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
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 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 an upper 
partial denture (D5213) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and panoramic x-rays (D0140, 
D0330) provided on May 25, 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 March 23, 2023 (D0210) 
and March 31, 2023 (D0140). Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation and panoramic x-rays (D0140, D0330) provided on May 25, 2023.