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

 
We decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no supportive evidence for the medical necessity of a TTE in this enrollee's clinical 
management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Transthoracic Echocardiography (TTE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower extremity revascularization procedures 
(37252 and 37253). 
 
You asked the Plan to pre-approve right lower extremity revascularization procedures. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 right lower extremity revascularization 
procedures. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is an appeal letter dated September 25, 2023, requesting approval of right lower extremity angiography 
and possible intervention. This letter makes no reference to the patient having undergone right lower extremity 
angiography and intervention just 10 days earlier on September 15, 2023. Since the intervention, there has been 
no reevaluation of the enrollee. The documentation, as presented, suggests a clerical error as there is an appeal 
for authorization of a procedure that was already recently done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right lower extremity revascularization procedures have not been met. 
Therefore, we decided that the Plan does not have to pre-approve right lower extremity revascularization 
procedures (37252 and 37253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on April 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the enrollee's 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 24, 2019. Therefore, 
we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), mechanical traction therapy (97012), 
and the electrical stimulation (G0283) provided from February 20, 2023, through April 24, 2023. 
 
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 these services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), mechanical traction therapy (97012), and the 
electrical stimulation (G0283) provided from February 20, 2023, through April 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says  the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips when each one-way trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953), a 
guided tissue regeneration (D4266), and the collection and application of autologous blood concentrate product 
(D7921) provided on March 20, 2023. 
 
You asked the Plan to pay for D7953, D4266, and D7921. You say that you believe the Plan should pay for 
this. The Plan denied your request. The Plan says the denied services are not covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953), a guided tissue regeneration (D4266), and the collection and 
application of autologous blood concentrate product (D7921) provided on March 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on March 17, 2023, 
by an out-of-network (OON) provider.  
  You asked the Plan to pay for the behavioral health services. You say that the visit was medically necessary 
because the enrollee does not have a primary care physician going to the facility. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on March 
17, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic colonography (CTC). 
 
You asked the Plan to pre-approve the CTC. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CTC. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the last colonoscopy was difficult, and a repeat 
direct colonoscopy would require withholding lifetime anticoagulants to do the procedure, and this is not 
advisable in a patient on lifetime anticoagulants. 
 
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 CTC have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomographic colonography (CTC).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on April 20, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the paramedics were 
called due to fainting. All vitals and the EKG were normal, and they stayed until the dizziness was gone. The 
Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without 
a transport there is no payable service. 
 
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 20, 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 ambulance treatment without transport provided 
on April 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission into a skilled nursing facility is medically 
necessary. The Plan denied your request. The Plan says admission into a skilled nursing facility is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a detailed and extensive oral evaluation and intraoral x-ray 
(D0160, D0210) provided on April 4, 2023, to April 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 February 6, 2023 
(D0160, D0210) and March 7, 2023 (D0160). Therefore, we decided that the Plan does not have to pay for a 
detailed and extensive oral evaluation and intraoral x-ray (D0160, D0210) provided on April 4, 2023, to April 
25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
20, 2023. 
 
You asked the Plan to pay for the dental service The Plan denied your request. The Plan says your benefit for 
the panoramic radiographic image 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 service was exhausted. Per your claim history, payment was issued for a 
related service D0210, on December 19, 2022. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330) provided on June 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on October 
5, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the enrollee had fallen 
due to blacking out. The paramedics stayed to monitor vitals. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
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 October 5, 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 ambulance treatment without transport provided 
on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were in severe pain. The Plan denied your 
request. The Plan says your annual dental allowance amount has 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 annual dental allowance amount was exhausted on date of service April 3, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on April 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on June 5, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the paramedics were 
called due to feeling faint, and they were there for less than 10 minutes. The Plan denied your request. The Plan 
says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
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 June 5, 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 ambulance treatment without transport provided 
on June 5, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided on March 1, 2022. 
 You asked the Plan to pay for the COVID-19 testing. You say that the testing should be fully covered under the 
Coronavirus Aid, Relief, and Economic Security (CARES) Act. 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 COVID-19 testing provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that recent CT results show moderate coronary artery 
vascular calcification. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary and when the criteria listed in the LCD in the Medicare rules section have been met.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found CT coronary calcium scoring is a non-
covered screening benefit in an asymptomatic patient. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a complete lower denture (D5120) 
provided on March 2, 2023. 
 
You asked the Plan to waive the copayment for the dental service. You say that your denture needed to be 
replaced and you would like the Plan to cover the replacement. 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 50% 
coinsurance for a complete denture. The total allowed amount was $1,125 and the total coinsurance amount 
was $562.50 ($1,125 allowed x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance for the dental service. This item/service falls within the 
complete denture 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 a complete lower 
denture (D5120) provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210) provided on March 21, 2023, to May 16, 2023. 
 
You asked the Plan to pay for the immediate denture - maxillary and extractions. You say that these services 
were previously approved. The Plan denied your request. The Plan says these services are not a covered 
expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an immediate 
denture - maxillary (D5130), and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 21, 2023, to May 
16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fabricated abutment (D6057) and an abutment support to 
crown (D6059) provided on June 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are entitled to $750 for the plan year and 
crowns are not excluded from the list. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because comprehensive dental services 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 
fabricated abutment (D6057) and an abutment support to crown (D6059) provided on June 7, 2023.