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

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#15. 
 
You asked the Plan to pre-approve the dental services. You say that without a crown you will not be able to 
consume solid food and the tooth is the only remaining biting tooth that you have left. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the crowns and core 
buildup are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and core buildup (D2950) for tooth #15.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires the daily physician 
supervision and nursing care provided in an LTACH. The Plan denied your request. The Plan says the enrollee 
is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our reviewer 
found the enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving care. The requested LTACH services are not appropriate for the diagnosis 
and condition of the enrollee. Services can be furnished safely and effectively on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to crown (D6058) for tooth #19 provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services were related to a crown and not a 
dental implant and the implant was medically necessary due to an infected tooth that was under a bridge. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because dental 
implants and implant related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057) and an abutment supported to crown (D6058) for tooth #19 provided on August 2, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator rendered on July 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J43.9 has an Excludes1 note in relation to J44.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
portable oxygen concentrator rendered on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of a mini implant, implant supported 
porcelain/ceramic crown, and bone replacement graft (D6013, D7953, D6065) provided on July 19, 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 services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical 
placement of a mini implant, implant supported porcelain/ceramic crown, and bone replacement graft (D6013, 
D7953, D6065) provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises provided by a chiropractor on July 
5, 2023, to July 20, 2023. 
 
You asked the Plan to pay for the therapeutic exercises. You say that customer service informed you that the 
chiropractic manipulative treatment is covered by the Plan. You say that you have lower back, neck, and 
shoulder pain. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 the therapeutic exercises provided by a chiropractor on July 5, 2023, to July 
20, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve HBO therapy to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
hyperbaric oxygen (HBO) therapy 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 pre-approve a cone beam (D0366), the guided tissue regeneration 
(D4266) for tooth #4, and the bone replacement graft (D7953) for tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are now 
medically necessary to get done now. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because the cone beam, the guided tissue regeneration, and the bone replacement 
graft are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam (D0366), the guided tissue regeneration (D4266) for tooth #4, and the bone replacement graft 
(D7953) for tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for spherocylinder, bifocal lenses (V2207), lenses with an 
index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass (V2783), anti-reflective coating 
(V2750), prism lenses (V2715), polarization (V2762), bifocal sphere lenses (V2200) provided from June 13, 
2023, to June 15, 2023. 
 
You asked the Plan to reimburse for spherocylinder, bifocal lenses (V2207), lenses with an index greater than 
or equal to 1.66 plastic or greater than or equal to 1.80 glass (V2783), anti-reflective coating (V2750), prism 
lenses (V2715), polarization (V2762), bifocal sphere lenses (V2200). You say that approximately every two 
years your prescription changes required new lenses. You also say you are asking for repayment from your 
insurance for these. The Plan denied your request. The Plan says services rendered by an out-of-network 
provider are not covered by the 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 when the eyewear is obtained through a Plan network vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for all eyewear costs from 
providers outside of the Plan vision network. Based on this information, we decided that the Plan's rules for 
coverage of spherocylinder, bifocal lenses (V2207), lenses with an index greater than or equal to 1.66 plastic or 
greater than or equal to 1.80 glass (V2783), anti-reflective coating (V2750), prism lenses (V2715), polarization 
(V2762), bifocal sphere lenses (V2200) have not been met. Therefore, we decided that the Plan does not have 
to reimburse for spherocylinder, bifocal lenses (V2207), lenses with an index greater than or equal to 1.66 
plastic or greater than or equal to 1.80 glass (V2783), anti-reflective coating (V2750), prism lenses (V2715), 
polarization (V2762), bifocal sphere lenses (V2200) provided from June 13, 2023, to June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete upper denture (D5750) and the reline 
of a complete lower denture (D5751) provided on August 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan, and they told you the dental 
services would be covered, and you have $2,000 worth of coverage. The Plan denied your request. The Plan 
says the denial of payment for these services is correct because the reline of dentures is not covered by the 
Plan. Also, it was verified you did not contact the Plan prior to the date of service to verify 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 reline 
of a complete upper denture (D5750) and the reline of a complete lower denture (D5751) provided on August 
7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) provided on June 23, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the denture was approved, and you would like 
the Plan to reverse 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 the Plan paid for an immediate lower denture (D5140) on November 16, 2022; therefore, your benefit 
for the requested item or service was exhausted on the date of service of November 16, 2022. Therefore, we 
decided that the Plan does not have to pay for a complete lower denture (D5120) provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0651, E0667) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 pneumatic compressor and segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve the routine transportation. You say that you need the transportation to make 
it to your appointments since you no longer drive. The Plan denied your request. The Plan says non-ambulance 
transportation is only covered through a plan-approved vendor from a hospital to a skilled nursing facility 
(SNF). 
 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 routine transportation when non-ambulance transportation is only covered through a 
plan-approved vendor from a hospital to a skilled nursing facility (SNF).  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
7, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that it was not necessary for 
the enrollee to go to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit 
is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 7, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumococcal vaccine provided on September 27, 2023. 
 You asked the Plan to pay for the vaccine. You say that the services were not related to the enrollee's hospice 
diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a pneumococcal vaccine provided on September 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 7, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you declined 
transportation to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve taxi transport services. 
 
You asked the Plan to pre-approve the taxi transport services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested services is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the taxi transport services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve taxi transport services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
April 27, 2023. 
 You asked the Plan to pay for the subsequent nursing facility care services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
April 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the continued IRF stay is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for the continued IRF stay.  
 
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 pre-approve 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF as medically necessary care can be provided in a different 
level of care.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.