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

 
We decided that the Plan does not have to pay for the dental services on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 28, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture. 
 
You asked the Plan to pre-approve the dental services. You say that you have never had dentures before and are 
not sure why they are being denied. The Plan denied your request. The Plan says these services are not covered 
by the Plan's 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 pre-approve a 
maxillary partial denture and mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular complete denture (D5110, 
D5120). 
 
You asked the Plan to pre-approve 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 pre-approve a 
maxillary and mandibular complete denture (D5110, D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye appointment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an eye appointment. You say that you need these visits and surgery so that 
you can see. This is causing a hardship in your daily life. The Plan denied your request. The Plan says there are 
other providers who can provide these services who are in-network. 
 
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 eye appointment to be provided by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the admission to 
a SNF 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 that you do not require daily skilled nursing and/or skilled therapy services. As a 
practical matter, you do not require admission to a SNF. 
 
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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network reconstructive surgery 
provided on December 15, 2022. 
 
You asked the Plan to waive the copayment for an in-network reconstructive surgery. You say that the Plan 
should have paid this in full. You want a full reimbursment. 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 surgery services. 
 
You have been asked to pay a $275 copayment for an in-network reconstructive surgery. This item/service falls 
within the surgery 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 in-
network reconstructive surgery provided on December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty robotic assistance and inpatient level of 
care for right total shoulder arthroplasty. 
 
You asked the Plan to pre-approve MAKOplasty robotic assistance and inpatient level of care. You say that 
you are experiencing too much pain. The Plan denied your request. The Plan says the clinical value and 
effectiveness of MAKOplasty have not been demonstrated and inpatient level of care is not appropriate for you. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that inpatient hospital care is covered when the doctor expects the 
patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may 
be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 MAKOplasty robotic assistance and 
inpatient level of care. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there are no large-volume, long-term, 
high-quality clinical studies that confirm the clinical benefits of computer-assisted surgery over standard 
surgical approaches in total shoulder arthroplasty. No compelling rationale or extenuating circumstance is 
presented to support the medical necessity of this request as an exception. Documentation is not evident 
regarding a significant past and/or current medical history that would place you at increased risk for surgical 
complications requiring an inpatient stay. An admitting physician would not reasonably expect that you 
necessary hospital care will span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MAKOplasty robotic assistance and inpatient level of care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve MAKOplasty robotic assistance and inpatient 
level of care for right total shoulder arthroplasty.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 10, 2022. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that the bill received is 
incorrect and should be processed properly. 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 $90 
copayment for emergency care.  
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 emergency room 
(ER) visit provided on October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on September 01, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you didnt 
receive the bill for the CT scan until December. 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 $175 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $175 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. the total you owe is $141.95, which is less than the standard $175 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on September 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82306, 82607, 82746, 83090 and 86141) 
provided on January 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says these services were provided as a screening 
and therefore are not covered in this case. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, laboratory services, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
laboratory services (82306, 82607, 82746, 83090 and 86141) provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
you. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found the available documentation does not indicate a condition for which coverage is available under the rules. The 
record also indicates that you are stable on BiPAP therapy. The provided primary source documentation does 
not contain sufficient detailed information in the medical record to justify the treatment selected. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bath tub wall rail. 
 
You asked the Plan to pre-approve bath tub wall rail. You say that you would like reconsideration because the 
requested bath tub wall rail is medically necessary. The Plan denied your request. The Plan says the requested 
bath tub wall rail is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve bath tub wall rail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (2LC11, G0152, G0299, G0151) 
provided on July 17, 2021, to July 29, 2021. 
 
You asked the Plan to pay for the home health 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 the claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the home health services was not filed until October 10, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services (2LC11, G0152, G0299, G0151) provided 
on July 17, 2021, to July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a power 
standing feature (E2301), modular knee blocks (K0108) and a transit tie down hardware (K0108). 

You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair accessories 
are medically necessary for you. The Plan denied your request. The Plan says a power seat elevation feature 
and a power standing feature are non-covered because they are not primarily medical in nature. The modular 
knee blocks are intended for use with the power standing feature and cannot be approved. The Plan also says 
the transit tie down hardware does not service a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a power standing 
feature (E2301), modular knee blocks (K0108) and a transit tie down hardware (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the chest provided on 
December 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan of the chest. You say that the services were necessary for your 
cough that other physicians could not diagnose. The Plan denied your request. The Plan says there were in-
network providers available you could have seen for your care. 
 
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 computed tomography (CT) of the chest 
provided on December 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a microslide consultation provided on July 21, 2022. 
 You asked the Plan to pay for a microslide consultation. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 6, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a microslide consultation 
provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and deep sedation/general anesthesia (D9223, 
D9222, D7210) provided on January 12, 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 an 
extraction and deep sedation/general anesthesia (D9223, D9222, D7210) provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D0220) provided on November 23, 2022, to January 3, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the limited oral evaluation and intraoral x-rays denied correctly as you were not 
enrolled in the Plan during the date of service November 23, 2022. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D0220) provided on November 23, 2022, to January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services provided on June 
16, 2022, and December 21, 2022. 
 
You asked the Plan to waive the copayments for the lab services. You say that these lab services were done 
through your primary care provider. 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 $20 
copayment for in-network lab services not performed by a primary care provider. 

The records show that the lab services were not processed by your primary care provider. You have been asked 
to pay a $20 copayment for each lab service. These items/services fall within the outpatient diagnostic tests and 
therapeutic 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 copayments for the laboratory 
services provided on June 16, 2022, and December 21, 2022.