Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6531 that 
were issued on April 25, 2023, to May 1, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6531 that were issued on April 25, 2023, to May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the 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 provided 
on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 18, 2023. 
 
You asked the Plan to pay for office visit. You say that you say that the assisted living facility was responsible 
for authorization. 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 office visit provided on 
January 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not a covered benefit because the 
enrollee is not participating in an approved clinical study or trial. 
 
The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid 
for the treatment of AD provided outside of a trial or study are nationally non-covered. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Specifically, there is no indication in the case record that the enrollee 
is participating in an approved trial or study. Therefore, we decided that the Plan does not have to pre-approve 
treatment with Leqembi (J0174).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 19, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
the ambulance but did not wish to be transported to the hospital by ambulance. You also say that you went to 
hospital emergency room in your vehicle driven by your friend. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
January 06, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you say that the plan 
should pay for this copayment. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency care 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 emergency room services 
provided on January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 27, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 nursing facility visit 
provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 1, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames and bifocal lenses provided on March 11, 2023. 
 
You asked the Plan to pay for frames and bifocal lenses. You say that the printout states frame, lenses and lens 
options should be covered up to $200. You also say that your total was $128.50, which is under the $200 
maximum. The Plan denied your request. The Plan says that the maximum benefit has been exceeded. 
 
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 offers a benefit up to $200 toward the purchase and fitting of eyeglasses and pair of lenses 
per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules also say the Plan offers a $200 benefit toward the 
purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also 
say you are responsible for any amount over the $200 retail price. The record shows that the submitted charge 
for these services was $257. The record also shows there was a discount given to the frames, thus leaving a 
balance of $4 for the frames and $52 for the bifocal lenses, which leaves a balance of $56. Based on this 
information, we decided that the Plan's rules for coverage of frames and bifocal lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for frames and bifocal lenses provided on March 11, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71110 billed for date of service February 1, 
2023.  
 
You asked the Plan to pay for procedure code 71110. You say that procedure code 71110 was not bundled with 
any other procedure performed on the same date of service (DOS). The claim was processed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 71110 is bundled into payment 
for code 71111. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71110 
is a column II code to column I code 71111 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71110 billed for date of service February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of benign lesion (D7410) provided on April 5, 2023. 
 
You asked the Plan to pay for excision of benign lesion (D7410). You say that this was not only a biopsy. You 
also say that the provider incorrectly coded this surgical procedure as only being a biopsy, which has been 
denied by the Plan. The Plan denied your request. The Plan says this oral procedure is regarded as a medical 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for excision 
of benign lesion (D7410) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions and an immediate denture (D7140, D5140) 
provided on April 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 you have a $0 copay up to the $2,000 allowance for all covered dental services. You pay 
100% of charges beyond the $2,000 allowance or if you exceed a service limit. 
 
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 extractions and an immediate denture (D7140, D5140) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for golf greens fees provided from November 23, 2022, to 
November 30, 2022. 
 
You asked the Plan to pay for golf greens fees. You say that you would like this reviewed. The Plan denied 
your request. The Plan says this is a non-covered service. The Plan also says that these services were denied for 
lack of itemized receipts, which is required to support all wellness wallet reimbursement claims. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers wellness 
benefits only when itemized receipts are received. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the Plan did not receive itemized 
receipts for this service. The record shows that the Plan reached out requesting itemized receipts. The record 
also showed that no itemized receipts were received. Therefore, we decided that the Plan does not have to pay 
for golf greens fees provided from November 23, 2022, to November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  osseous surgery-4 or more teeth (D4260 x2) and bone 
replacement graft- first site (D4263 x 2). Inhalation of nitrous oxide/analgesia, anxiolysis (D9230) is a covered 
service but there is a 50% coinsurance for this service provided on April 14, 2023. 
 
You asked the Plan to pay for osseous surgery, bone replacement graft and inhalation of nitrous 
oxide/analgesia, anxiolysis. You say that this should be covered. The Plan denied your request. The Plan says 
osseous surgery and bone replacement graft 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  osseous 
surgery-4 or more teeth (D4260 x2) and bone replacement graft- first site (D4263 x 2) and inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230) provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom abutment (D6057) and an abutment supported to 
crown (D6059) for tooth #11 provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to get the implant and you did not 
know that there was no coverage for dental implants or any part of the process. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the custom abutment and an abutment 
supported to crown are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
abutment (D6057) and an abutment supported to crown (D6059) for tooth #11 provided on May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain full function and 
mobility after surgery. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for golf greens fees provided from November 17, 2022, to 
November 29, 2022. 
 
You asked the Plan to pay for golf greens fees. You say that you would like this reviewed. The Plan denied 
your request. The Plan says this is a non-covered service. The Plan also says that these services were denied for 
lack of itemized receipts, which is required to support all wellness wallet reimbursement claims. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers wellness 
benefits only when itemized receipts are received. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the Plan did not receive itemized 
receipts for this service. The record shows that the Plan reached out requesting itemized receipts. The record 
also showed that no itemized receipts were received. Therefore, we decided that the Plan does not have to pay 
for golf greens fees provided from November 17, 2022, to November 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance did not take you to the hospital. You also say that you were treated at home and the provider should 
send the claim back to the plan with the correct codes. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274 X3) provided 
on April 5, 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 April 5, 2023. Therefore, 
we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274 X3) provided 
on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection device for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller, harness, and electronic connection. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says the enrollee's upper limb 
strength and function are adequate to control the wheelchair's power options through their own switches. 
 
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 expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate upper body 
strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and 
electronic connection device for a power wheelchair.