Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent telehealth consultation (G0509) provided on 
July 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that a practice note dated August 28, 2023, 
indicates that our services do not require authorization. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 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 subsequent telehealth consultation (G0509) 
provided on July 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D9230) on August 9, 2023. 
 
You asked the Plan to pay for the dental service (D9230). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the 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 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 dental 
service (D9230) on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D6740 and D6245) on August 31, 2023. 
 
You asked the Plan to pay for the dental services (D6740 and D6245). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services requested 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 the dental 
services (D6740 and D6245) on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation with a medicinal agent - per quadrant 
(D4921) provided on September 8, 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 June 3, 2023. Therefore, 
we decided that the Plan does not have to pay for gingival irrigation with a medicinal agent - per quadrant 
(D4921) provided on September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 02, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider. 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 subsequent nursing 
facility care provided on August 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 13, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. 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 lab services provided on 
September 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from SEPTEMBER 24, 2023, through SEPTEMBER 24, 2023. 
 
You asked the Plan to pay for the IRF care. You say that you needed this care. The Plan denied your request. 
The Plan says your medical condition does not require IRF services, and care can be provided in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from SEPTEMBER 
24, 2023, through SEPTEMBER 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 27, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on October 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth consultations, and subsequent nursing facility care 
provided on June 07, 2023, to June 12, 2023. 
 
You asked the Plan to pay for telehealth consultations, and subsequent nursing facility care. You say that the 
enrollee was in a nursing home at the time services were rendered. 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 telehealth consultations, 
and subsequent nursing facility care provided on June 07, 2023, to June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. 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 September 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740) provided on August 
22, 2023. 
 
You asked the Plan to pay for the crowns. The Plan denied your request. The Plan says this service is 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 the crowns - 
porcelain/ceramic (D2740) provided on August 22, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the rehabilitation services provided from 
August 16, 2022, to January 4, 2023. 
 
You asked the Plan to provide reimbursement for the rehabilitation services. You say that you are reconsidering 
reconsideration of the denied reimbursement. The Plan denied your request. The Plan says these services are 
not covered when received outside the United States.  
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care. The Plan contract says that rehabilitation services outside the United States are not 
emergent and are not covered.   
 
The record shows the rehabilitation services were provided outside the United States and were not emergent. 
Therefore, we decided that the Plan does not have to provide reimbursement for the rehabilitation services 
provided from August 16, 2022, to January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940, 98941). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
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.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, Medicare rules say that the only covered 
chiropractic service is manual manipulation of the spine to correct a subluxation.   
 
 
The record does not demonstrate that you have requested chiropractic services on the basis of this diagnosis. 
Therefore, you do not meet criteria for coverage of the requested services. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic manipulative treatments (98940, 98941).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 6, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were having issues with your front teeth and 
your dentist sent you to a specialist. 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 the Plan paid for a limited oral evaluation (D0140) on July 25, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of July 25, 2023. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation (D0140) provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that you had the previous denture repaired twice 
and it only lasted for 2 weeks. 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 the Plan paid for a complete upper denture (D5110) on July 14, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of July 14, 2021. Therefore, we decided that the 
Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
requested on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on October 30, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that you would like reconsideration based on the 
records submitted. 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 nursing facility care. 
provided on October 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more a complete upper denture (D5110) and to pre-
approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve more the dental services. You say that you dental coverage should cover 
your dental needs and you should not have to come out of pocket for coverage. The Plan denied your request. 
The Plan says your annual dental maximum benefit for the year 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 the Plan paid $99 for dental services on September 12, 2023. On November 16, 2023, the Plan pre-
approved $901 for dental services. For the year of 2023 the Plan has paid and pre-approved $1,000 ($99 paid + 
$901 pre-approved) for dental services; therefore, your annual dental maximum benefit for the year of 2023 
was exhausted on the date of approval of November 16, 2023. Therefore, we decided that the Plan does not 
have to pre-approve more a complete upper denture (D5110) and to pre-approve a complete lower denture 
(D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. The cause of pain is not clear.   
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional Papa Pals hours. 
 
You asked the Plan to pre-approve the additional Papa Pals hours. You say that the enrollee is visually 
impaired and requires this service to maintain some level of socialization and to keep her small living area 
clean and tidy. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover in-home support services. However, the Plan offers an in-home support 
services benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an in-home support services benefit in excess of Medicare coverage, certain limitations 
apply. The record shows your benefit for the requested item or service was exhausted on October 12, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the additional Papa Pals hours.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120), the intraoral 
complete series of radiographic images (D0210), and a cleaning (D1110) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have been going to the same dentist for 
15 years and you would like the Plan to make an exemption so you can continue going to the same provider. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve a periodic 
oral evaluation (D0120), the intraoral complete series of radiographic images (D0210), and a cleaning (D1110) 
to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D4266 and D7950) on March 2, 2023. 
 
You asked the Plan to pay for the dental services (D4266 and D7950). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services requested 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 the dental 
services (D4266 and D7950) on March 2, 2023.