Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that the enrollee needs 4 additional trips for 
doctor's appointments. The Plan denied your request. The Plan says the enrollee has used 12 of this service and 
their benefits are exhausted. 
 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 a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approved 
additional trips for the enrollees doctors appointments. 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 transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for diagnostic casts (D0470) provided on January 26, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe this should be paid. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for diagnostic casts (D0470) provided on 
January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5253) provided on May 4, 2023. 
 
You asked the Plan to pay for hearing aids (V5253). You say that based on quality and affordability, you 
purchased the physician ordered hearing aids through this rendering provider. The Plan denied your request. 
The Plan says the claim denied correctly as not a benefit because the member did not go to a Plan hearing 
provider as directed. 
 
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 you obtain the hearing aids from a Plan hearing provider.  
 
We looked at the file and the Plan's rules. The Plan rules say that hearing aids must be purchased through a 
Plan hearing provider. The record shows that your hearing aids were purchased through an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids (V5253) have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5253) provided on 
May 4, 2023.  
 Your complaint about the Plan potentially forcing senior citizens to pay substantially more for the hearing aids 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of an intra-socket biological dressing to aid in 
hemostasis or clot stabilization, per site (D7922) provided on April 5, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the placement of 
an intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) provided on  
April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308, 99309) provided 
on March 16, 2022, through March 22, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the service should be covered. 
The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent nursing facility care was not filed until March 23, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308, 
99309) provided on March 16, 2022, through March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (A6530).  
You asked the Plan to pre-approve gradient compression stockings. You say that the item is necessary. The 
Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that certain wound care items are non-covered under 
the surgical dressing benefit because they do not meet the statutory definition of a dressing 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gradient compression stockings have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gradient compression stockings (A6530).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections.. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does meet the LCD criteria for coverage. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD requires advanced imaging such as an MRI or CT scan.  Since this has not 
been done, the request is deemed 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 facet joint injections. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for polarization vision lenses (V2762) provided on October 13, 2022. 
 
You asked the Plan to pay for polarization vision lenses (V2762). You say that you require glasses for full time 
wear to be able to see both in the distance and near. You also say you are prone to falling and have a history of 
spinal fractures. The Plan denied your request. The Plan says that polarization vision lenses (V2762) is not 
covered under your benefit plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan will pay for a routine eye 
examination and eyeglasses once every two years. The Plan rules also say eyeglass lenses are covered more 
than once every two years only if it is medically necessary. The record shows that the Plan covers eyeglasses 
and lenses. Specifically, the Plan contract does not specify that they do not cover specific types of lenses. The 
contract simply states they cover lenses. Based on this information, we decided that the Plan's rules for 
coverage of polarization vision lenses (V2762) have been met. Therefore, we decided that the Plan has to pay 
for polarization vision lenses (V2762) provided on October 13, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical spine surgery (arthrodesis).  
 
You asked the Plan to pre-approve the cervical spine surgery. You say that the surgery is medically necessary.  
The Plan denied your request. The Plan says the arthrodesis is not medically necessary. The Plan says the 
enrollee has failed to undergo conservative management.  
 
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 cervical spine surgery. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found more conservative measures are needed. The documentation does not show a recent trial and 
failure of six weeks of physical 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 cervical spine surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cervical spine surgery (arthrodesis).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement of a crown (D2920) provided on January 24, 
2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the recement of a 
crown (D2920) provided on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan and an EKG provided on March 
22, 2023. 
 
You asked the Plan to waive the copayment for a CT scan and an EKG. You say that your physician insisted 
you received these procedures prior to your surgery. 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 $150 
copayment for each type of Medicare-covered diagnostic radiology service, including a CT scan, and a $35 
copayment for each outpatient x-ray, diagnostic procedure and test.  
 You have been asked to pay a $185 copayment for a CT scan and an EKG. This item/service falls within the 
outpatient diagnostic tests 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 CT scan 
and an EKG provided on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2392), a crown (D2750), and a 
core build-up (D2950) provided on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 resin-
based composites (D2392), a crown (D2750), and a core build-up (D2950) provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2331) for tooth #22 and #25 
provided on May 25, 2023. 
 You asked the Plan to pay for the dental services. You say that you do not think you should be charged out-of-
network prices since there is no good in-network dentist. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the resin-based composite 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2331) for tooth #22 and #25 provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing - four or more 
teeth per quadrant (D0120), and prophylaxis - adult (D1110) provided on March 23, 2023. 
 
You asked the Plan to pay more for the periodontal scaling and root planing and prophylaxis - adult. You say 
that your benefits say these services would be paid at 100% so you should be reimbursed the $145.00 you paid. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for periodontal scaling and root planing - four or 
more teeth per quadrant (D0120), and prophylaxis - adult (D1110) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for 2 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the gingival irrigation 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 Plan's 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 
gingival irrigation (D4921) for 2 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Trilogy home ventilator provided on December 19, 2022, 
to February 18, 2023. 
 You asked the Plan to pay for the Trilogy home ventilator. You say that the medical records have been 
submitted for review and are asking to have the claim processed for these dates of service.  The Plan denied 
your request. The Plan says the records submitted do not support the enrollee's medical need for the Trilogy 
home ventilator.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 pay for the Trilogy home ventilator. Our reviewer 
says that the Trilogy home ventilator was not medically necessary. Our physician reviewer found although the 
enrollee has documented COPD and chronic respiratory failure, there is no data to support need for the home 
ventilator. The documentation is lacking and sparse ot evidence or rationale for the ventilator. It is unclear if 
the enrollee is on or has been on a Trilogy ventilator. 
 
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 Trilogy home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pay for a Trilogy home ventilator provided on December 19, 2022, to February 18, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a screening mammogram and breast tomosynthesis (77067 & 77063). 
 
You asked the Plan to pay for a screening mammogram and breast tomosynthesis. You say that the services 
should be covered. The Plan denied your request. The Plan says that they are not the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for a screening mammogram and breast tomosynthesis (77067 & 
77063).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99222-GC provided on February 8, 2023. 
 
You asked the Plan to pay for procedure code 99222-GC. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the procedure code was billed with a 
modifier that is inappropriate or invalid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the file shows that the evaluation and management (E/M) services 
were performed in part by a Resident under the direction of a teaching physician. The correct GC modifier was 
billed with procedure code 99222. The Plan provided no other rationale for their denial of payment, and we 
must find in your favor. Therefore, we decided that the Plan has to pay for procedure code 99222-GC provided 
on February 8, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete mandibular denture (direct) (D5731) 
provided on May 24, 2023. 
 
You asked the Plan to pay for the reline complete mandibular denture. You say that the provider did not 
confirm the frequency for the reline benefit and you should not be held responsible. The Plan denied your 
request. The Plan says your benefit for the reline complete mandibular denture 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 on date of service May 24, 2023. You already 
received the allowed frequency of 1 reline complete maxillary denture (direct) (D5730) on the appealed claim. 
Therefore, we decided that the Plan does not have to pay for the reline complete mandibular denture (direct) 
(D5731) provided on May 24, 2023.