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

 
We decided that the Plan does not have to pay for ambulance transport services provided on January 24, 2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that the enrollee had two ambulance 
transportations for this date of service. The Plan denied your request. The Plan says based on the information 
received the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized 
diagnostic or therapeutic services not available at the facility where the patient is an inpatient. 
 
We looked at the file and Medicare rules. The enrollee was a hospital inpatient at the time of service and was 
transported to a separate facility for testing which means this ambulance service is included in the inpatient 
payment and is not separately paid by Medicare. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transport services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transport services provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), unspecified periodontal 
procedure (D4999) and oral hygiene instructions (D1330) provided on January 20, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this 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 gingival 
irrigation (D4921), unspecified periodontal procedure (D4999) and oral hygiene instructions (D1330) provided 
on January 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 26, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 14, 2023, to March 28, 
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 $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on March 14, 2023, to March 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aimovig.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a hearing aid (V5298) purchased on February 10, 
2023. 
 
You asked the Plan to reimburse for a hearing aid (V5298). You say that you can see an in-network or out-of-
network provider for your hearing aids. The Plan denied your request. The Plan says the hearing benefit is not 
covered if the services are not ordered through this designated vendor. 
 
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 hearing aids are purchased inside of the Plan hearing network.  
 
We looked at the file and the Plan's rules. The Plan rules say that hearing aids purchased outside of the Plan 
hearing network are not covered. The record shows these hearing aids were not purchased in-network. Based 
on this information, we decided that the Plan's rules for coverage of a hearing aid (V5298) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for a hearing aid (V5298) purchased on 
February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that this surgery will greatly improve the enrollee's 
pain, functionality, and mobility. The Plan denied your request. The Plan says the enrollee's chronic back pain 
suggests it is not acute. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if certain 
criteria are 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is no trial of fracture 
bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T10 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services provided by your chiropractor on 
November 22, 2022. 
 
You asked the Plan to pay for the therapeutic services. You say that you previously tried a physical therapist, 
but the treatments were not as effective. The Plan denied your request. The Plan says that this service is not 
covered when it is billed by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic services provided by your chiropractor on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
oral hygiene instruction (D1330) and adjunctive pre-diagnostic test (D0431) provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that your wife submitted an identical claim, and it 
was paid. The Plan denied your request. The Plan says this request was submitted without a charged amount. 
 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 oral hygiene instruction (D1330) 
and adjunctive pre-diagnostic test (D0431) are not among those covered under this benefit. Additionally, the 
Plan is only obligated to pay their share of the cost for covered dental services that have a balance owed. The 
records show the full amount of the charges billed were adjusted to $0 by the provider, which would not 
require additional payment from the Plan. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), prophylaxis (D1110), oral hygiene instruction (D1330) and adjunctive pre-
diagnostic test (D0431) provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline of a complete upper denture (D5750) provided on 
February 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to consider the 
procedure as a normal dental procedure and the prosthetic was medically necessary. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the reline of a complete upper 
denture 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a reline of 
a complete upper denture (D5750) provided on February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer implantable pulse generator. 
 
You asked the Plan to pre-approve an Optimizer implantable pulse generator. You say that the requested 
Optimizer implantable pulse generator is medically necessary. The Plan denied your request. The Plan says the 
requested Optimizer implantable pulse generator 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 an Optimizer implantable pulse 
generator. Our reviewer says that the requested Optimizer implantable pulse generator is not medically 
necessary. Our physician reviewer found an exhaustive review of the current medical literature pertaining to 
the Optimizer implantable pulse generator, or cardiac contractility modulation (CCM) system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, 
with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, I would not consider the CCM system to be 
medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer implantable pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Optimizer implantable pulse generator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty. 
 
You asked the Plan to pre-approve knee arthroplasty. You say that this procedure is in the enrollee's best 
interest. 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 knee arthroplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less-invasive conservative care measures is not evident. The enrollee has not attended a formal therapy course 
or trialed any injection therapy outside of cortisone. The knee imaging studies are not provided for review of 
the pathology. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 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 knee arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740) provided on March 10, 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 10, 2023. 
Therefore, we decided that the Plan does not have to pay for a retainer crown (D6740) provided on March 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a hearing aid (V5298) purchased on November 4, 
2022. 
 
You asked the Plan to reimburse for a hearing aid (V5298) . You say that the price at this vendor is a whole lot 
better. You also say that with these hearing aids, you no longer ask people to repeat, the volume of the 
television is way down, and you can hear in church. The Plan denied your request. The Plan says hearing aids 
must be purchased through the Plan to be covered under the hearing aid services offered by your plan. 
 
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 hearing aids ordered through Plan network providers.  
 
 
  We looked at the file and the Plan's rules. The Plan rules also say that hearing aids ordered through providers 
other than Plan hearing network vendors are not covered. The record shows that the hearing aids you purchased 
were not purchased through a network provider. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298)  have not been met. Therefore, we decided that the Plan does not have to 
reimburse for a hearing aid (V5298) purchased on November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for progressive lenses (V2781) provided on January 24, 
2023.  
You asked the Plan to reimburse for progressive lenses (V2781). You say that you were told that the vendor 
would be covered for eyewear. The Plan denied your request. The Plan says the Plan does not cover this out-of-
network vision care service/material. 
 
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 when the service is provided in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must receive your care from a network 
provider. The record shows you purchased your eyewear from an out-of-network provider. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781) have not been met.  
Therefore, we decided that the Plan does not have to reimburse for progressive lenses (V2781) provided on 
January 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy x22 visits to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve occupational therapy x22 visits. You say that you do not agree with the 
denial of occupational therapy visits by an OON provider. The Plan denied your request. The Plan says the 
service can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
occupational therapy x22 visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on April 3, 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 May 27, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, panoramic x-ray, 
immediate mandibular dentures, extractions, and the removal of the torus mandibular (D0150, D0330, D5140, 
D7210 x4, D7140 x4, D7473 x2) provided on February 17, 2023, to March 13, 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 the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  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, panoramic x-ray, immediate mandibular dentures, extractions, and 
the removal of the torus mandibular (D0150, D0330, D5140, D7210 x4, D7140 x4, D7473 x2) provided on 
February 17, 2023, to March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the fitting of contact lens (92072) purchased on 
November 2, 2022. 
 
You asked the Plan to reimburse for the fitting of contact lens (92072). You say that this is a single appended 
claim for reimbursement for the medical required contact lenses costs. The Plan denied your request. The Plan 
says this benefit had been exhausted on his contact lens purchase. 
 
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 up to $150 toward for supplemental frames, lenses, prescription contacts (instead of 
eyeglasses), or upgrades every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan covers up to $150 toward for 
supplemental frames, lenses, prescription contacts (instead of eyeglasses), or upgrades every two years. The 
record shows this benefit was exhausted on November 14, 2022. Based on this information, we decided that the 
Plan's rules for coverage of fitting of contact lens (92072) have not been met. Therefore, we decided that the 
Plan does not have to reimburse for the fitting of contact lens (92072) purchased on November 2, 2022.