Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee roller purchased on January 12, 2023, from a non-
certified provider. 
 
You asked the Plan to pay for a knee roller. You say that the item should be covered. The Plan denied your 
request. The Plan says you purchased this item through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a knee roller purchased on January 12, 
2023, from a non-certified provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedures (D5899) 
provided on March 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that your dentures would 
not be covered by the Plan. The Plan denied your request. The Plan says the denial of payment for these 
services is correct because the unspecified removable prosthodontic procedures are not covered by the Plan. 
Also, it was verified that the upper and lower dentures were fully covered. 
 
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 
unspecified removable prosthodontic procedures (D5899) provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
22, 2023. We also decided the Plan does not have to pay more for a comprehensive oral evaluation (D0150) 
provided on March 22, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image (D0330) and to pay more for a comprehensive 
oral evaluation (D0150). You say that you are in need of dentures, and was getting a second opinion as 
dentures are very expensive. The Plan denied your request. The Plan says your benefit for a panoramic 
radiographic image (D0330) has already been exhausted. The Plan also says that the comprehensive oral 
evaluation (D0150) has been exhausted and they paid the correct cost sharing amount. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a panoramic radiographic image (D0330) was exhausted on date of service March 17, 
2023. The record also shows the Plan paid the correct cost sharing amount for the comprehensive oral 
evaluation (D0150). The record also shows that this service has also been exhausted. Therefore, we decided 
that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 22, 2023. 
We have also decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) 
provided on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of the implant bodies (D6010) 
provided on March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that prosthodontics for missing teeth is covered 
under your plan so it should include dental implants. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because implants and all 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 the 
surgical placement of the implant bodies (D6010) provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction, the office visit, and the ophthalmic ultrasound 
provided on January 17, 2023. 
 
You asked the Plan to pay for the refraction, the office visit, and the ophthalmic ultrasound. You say that your 
primary care physician should be responsible for the additional charges from the eye doctor. You say if you had 
known there would be additional charges at your routine eye exam, you would not have seen this eye doctor. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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 eye refraction is provided during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows a dry eye diagnosis which makes the 
services medical in nature. This means the refraction is not covered under your supplemental benefits.  
 
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 $40 
copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered 
benefits and a $100 copayment for other Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay a $40 copayment for the office visit. This service falls within vision care benefit 
category. You have also been asked to pay $11.46, which is less than the standard copayment, for the 
ophthalmic ultrasound. This service falls within the outpatient diagnostic tests and therapeutic services and 
supplies. 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. Based on this 
information, we decided that the Plan's rules for coverage of the refraction, the office visit, and the ophthalmic 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the refraction, the 
office visit, and the ophthalmic ultrasound provided on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, abdomen (74150). 
 
You asked the Plan to pre-approve a Computed tomography. The Plan denied your request. The Plan says since 
the enrollee just had a CT study of the same type done 2 months ago and because there is no indication why 
another one is needed now, coverage is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 Computed tomography. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee just had a CT study 
of the same type done 2 months prior to this request and as there was no new symptoms or findings from the 
last encounter that would warrant a newer CT scan, this request for CT abdomen will be considered not 
medically necessary at this time.  
 
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 Computed tomography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Computed tomography, abdomen (74150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), the bitewings 
(D0274), and a cleaning (D1110) provided by an out-of-network provider on March 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have out-of-network coverage and 
you paid the bill in full. 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.  
 
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 total amount billed for the periodic oral evaluation (D0120) was $54.40 and the total allowed amount was 
$30 leaving a difference of $24.40 ($54.40 billed - $30 allowed). The total amount billed for the bitewings 
(D0274) was $72.25 and the total allowed amount was $36 leaving a difference of $36.25 ($72.25 billed - $36 
allowed). The total amount billed for the cleaning (D1110) was $95.20 and the total allowed amount was $55 
leaving a difference of $40.20 ($95.20 billed - $55 allowed). The total difference amount for all the dental 
services was $100.85 ($24.40 difference + $36.25 difference + $40.20 difference). 
 
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 the periodic oral evaluation (D0120), the 
bitewings (D0274), and a cleaning (D1110) provided by an out-of-network provider on March 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency wheelchair van transportation service 
(A0130) provided on January 19, 2023. 
 
You asked the Plan to pay for the wheelchair van transportation service. You say that you did not have an 
option to choose this transportation. You also say that the ambulance service was to bring you to the 
rehabilitation facility using the chair van. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency wheelchair van transportation service (A0130) provided 
on January 19, 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. The Plan denied your request. The Plan says needed care can be 
provided at a lower level such as skilled nursing facility (SNF). 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 very heavy duty power operated vehicle 
(POV) with a patient weight capacity 451 to 600 pounds (K0802) 
 
You asked the Plan to pre-approve a group 1 very heavy duty POV. You say that you need assistance so that 
you can go places and get around for things you need. You also say that you are not able to do anything, need 
some assistance, and the scooter was able to help you out tremendously. The Plan denied your request. The 
Plan says your weight is too low for this particular scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class POV. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 1 very heavy duty POV have not been met. Specifically, the provided records show that 
your most recent documented weight is below the required weight limit of 451 to 600 pounds for the requested 
group 1 very heavy duty POV (K0802). Therefore, we decided that the Plan does not have to pre-approve a 
group 1 very heavy duty power operated vehicle (POV) with a patient weight capacity 451 to 600 pounds 
(K0802)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the 
requested testing. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is the age 85, therefore the criteria is not 
met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 4, 2022, to November 
18, 2022, by an OON provider.  
 
You asked the Plan to pay for wound care. 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 wound care provided on November 4, 2022, to 
November 18, 2022, by an OON provider.
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 services are medically necessary to provide the 
enrollee the best opportunity to regain their prior level of function. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crown on tooth # 11 (D2750). 
 
You asked the Plan to pre-approve a crown . You say that this is medically necessary. The Plan denied your 
request. The Plan says that they reviewed all the information on file from the dentist. This information did not 
include evidence of pathological destruction to the tooth that meets the above criteria. 
 
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 a crown 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 a crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a filling will not be adequate in restoring the 
tooth as the filling material can shear off. If left untreated without a crown, the enrollees tooth may fracture into 
pieces, and may lead to loss of the tooth in the future for the enrollee. Noting the photographs and x-rays 
submitted, this tooth is vital in helping the patient eat of her food. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
crown on tooth # 11 (D2750).  
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient  
(D0150), prophylaxis - adult (D1110), topical application of fluoride varnish (D1206), and intraoral - complete 
series of radiographic images (D0210) provided on March 28, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0150, D1110, D1206 and D0210. You 
say that you have Sjogrens Syndrome and were surprised the Plan did not pay for the cost of your out-of-
network visit when it has paid in the past.  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 services are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation - new or established patient  (D0150), prophylaxis - adult (D1110), topical 
application of fluoride varnish (D1206), and intraoral - complete series of radiographic images (D0210) 
provided on March 28, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xF testing (81455) provided on January 16, 2023. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test is medically necessary and appropriate. 
The Plan denied your request. The Plan says that this test is not considered medically necessary as it is not 
FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Tempus xF testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found per the National Comprehensive Cancer Network (NCCN) Guidelines, understanding the 
molecular drivers of cancer progression and metastases is an area of ongoing and active research, 
predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in 
individualized cancer treatment. In addition to likely providing prognostic information, the value of next 
generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. 
Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may 
indicate benefit from targeted treatment or clinical trials. It is considered a standard of care. The service was 
reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have been met. Therefore, we decided that the Plan has to 
pay for Tempus xF testing (81455) provided on January 16, 2023.  
 
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.