Persius/hicric huggingface dataset:
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 you need the SNF care due to your medical 
condition. The Plan denied your request. The Plan says the SNF admission 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on January 31, 2023. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you are requesting reconsideration of the 
denied claim. 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 the outpatient clinic visit 
provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified periodontal procedures (D4999) provided on 
May 9, 2023. We also decided that the Plan does not have to waive the copayment for periodontal scaling and 
root planing (D4341) for the upper left and lower left quadrants provided on Mary 9, 2023. 
 
You asked the Plan to pay for unspecified periodontal procedures (D4999). You also asked the Plan to waive 
the copayment for periodontal scaling and root planing (D4341) for the upper left and lower left quadrants. 
You say that you are appealing your dental service charges for May 9, 2023. You also say that it was your 
understanding when you signed up for this policy that it had $50,000 in dental benefits. The Plan denied your 
request. The Plan says unspecified periodontal procedures (D4999) are uncovered benefits. The Plan also says 
this cost sharing for periodontal scaling and root planing (D4341) for the upper left and lower left quadrants 
was charged correctly. 
 
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, unspecified periodontal procedures 
(D4999) are not among those covered under this benefit.  
 
The rules also 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 $115 copayment for periodontal scaling and root planing (D4341). 
 
You have been asked to pay a $115 copayment for periodontal scaling and root planing (D4341) for the upper 
left and lower left quadrants. This item/service falls within the periodontal scaling and root planing (D4341) 
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 pay for unspecified periodontal procedures (D4999) 
provided on May 9, 2023. We also decided that the Plan does not have to waive the copayment for periodontal 
scaling and root planing (D4341) for the upper left and lower left quadrants provided on Mary 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery on January 11, 2023. 
 
You asked the Plan to waive the cost share for outpatient surgery. You say that you want to appeal the amount 
being charged.  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 10% 
coinsurance of the approved amount. The annual deductible applies for hospital services. Covered services 
include but are not limited to services in an outpatient clinic, such as observation services or outpatient surgery. 
The provider billed in the amount of $275 and the allowed amount is $260.85 for the service. Therefore, results 
in the total cost sharing amount of $260.85. 
 
You have been asked to pay a $260.85 cost share for outpatient surgery. This item/service falls within the 
hospital services 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 cost share for outpatient surgery on 
January 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha syringe. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare says Part B doesn't usually cover 'self-administered' drugs. 
 
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 Repatha syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy provided on April 27, 2023. 
 
You asked the Plan to pay for the outpatient therapy. You say that you are requesting reconsideration of the 
denied claim. 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 the outpatient therapy 
provided on April 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, thorax provided on April 27, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the CT scan, thorax. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 CT scan, thorax provided on April 27, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day reader. You say that you will need this it has been 
a tool that helps you keep my numbers at an acceptable level. You also say that you would like to receive the 
FreeStyle Libre again. The Plan denied your request. The Plan says based on the information provided on 
appeal the criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable 
and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the 
information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a FreeStyle Libre 14-day reader have 
been met. Specifically, medical records were not provided for this case. The record shows that the Plan made 
multiple attempts to obtain this information, but it was not received. The provider also has not confirmed if you 
are on insulin or have a history of problematic hypoglycemia. Without this information we are unable to 
determine if the criteria for coverage have been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14-day reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a manual wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are other providers available who are in-network, who are within the 
Medicare allowable distance from the patient's residence. 
 
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 
a manual wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on October 17, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the doctor provided service to the member in 
good faith and should be reimbursed for the services. The Plan denied your request. The Plan says out-of-
network virtual care is not covered under the members benefit plan. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network.  
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services 
out-of-network. Based on this information, we decided that the Plans rules for coverage of the telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on October 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy x12 visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy x12 visits. You say that you do not agree with the denial of 
the requested services. 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 
physical therapy x12 visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 02, 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 December 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
February 28, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you had no other 
option but to take the ambulance. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for an ambulance transportation. This item/service falls within 
the ambulance services 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 an 
ambulance transportation provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided on March 31, 2023. 
 
You asked the Plan to pay for hearing aids (V5298). You say that you went to one of the hearing centers that 
the Plan approved, you would be paying twice the amount that this rendering provider charged you. The Plan 
denied your request. The Plan says there is no coverage if hearing aids, or related services are received from 
outside of the Plan hearing network. The Plan also says that the hearing benefit is not covered if the services 
are not registered in advance. 
 
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 gym benefits 
only when they are purchased in-network. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the hearing aids were purchased out-
of-network. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298) provided on 
March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277), 
prophylaxis - adult   (D1110), resin-based composite - three surfaces, posterior (D2393), resin-based composite 
- one surface, posterior (D2391) crown - porcelain/ceramic (D2740), and intraoral - periapical first 
radiographic image (D0220) provided on October 13, 2022, and March 29, 2023. 
 
  
You asked the Plan to pay for the dental services. You say that it was not until your most recent visit you 
discovered you are now enrolled in HMO dental coverage. You also say that the dentist looked up your account 
and found no indication of the HMO service. 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 vertical bitewings - 7 to 8 radiographic images (D0277), prophylaxis - adult   (D1110), resin-based 
composite - three surfaces, posterior (D2393), resin-based composite - one surface, posterior (D2391) crown - 
porcelain/ceramic (D2740), and intraoral - periapical first radiographic image (D0220) provided on October 13, 
2022, and March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic (D6245) for tooth #5 and retainer crowns (D6740) for 
tooth #3 and #5. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee can only wear a denture if all 
their teeth were extracted. The Plan denied your request. The Plan says that there is no documentation that 
would preclude placement of a removable prosthesis. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the replacement fixed bridge is medically reasonable and necessary. Our physician reviewer found that the 
documentation indicates that the current bridge is 25 years old and due to recurrent caries needs replacement.  
There are no other missing teeth in the arch. The documentation provided meets the criteria for coverage for a 
replacement fixed bridge replacing missing tooth #4 with a pontic (D6245) using teeth #3 and #5 as abutment 
retainers (D6740). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a pontic (D6245) for tooth #5 and retainer crowns (D6740) for tooth #3 and #5.  
 
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.