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

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on January 18, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you do not believe that your claim 
request should be denied just by simply stating that the provider not part of vendor network. The Plan denied 
your request. The Plan says this provider is not part of the vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are purchased by a network vendor. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aid (V5298) have not been met. Therefore, we decided that the Plan 
does not have to reimburse for hearing aids (V5298) purchased on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) provided on November 28, 2022.  
You asked the Plan to pay for frames (V2020). You say that you are providing records in your request for 
reimbursement under your Plan. The Plan denied your request. The Plan says vision services, in regard to 
eyeglasses or contact lenses, are not covered by the plan, unless obtained after cataract 
surgery. 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. The Plan says that they cover one pair of eyeglasses or contact lenses 
after each cataract surgery that includes insertion of an intraocular lens. The record shows your frames are not 
covered by this benefit plan. Based on this information, we decided that the Plan's rules for coverage of frames 
(V2020) have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020) 
provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supplies/accessories (V2797) and sales tax (S9999) 
purchased on November 22, 2022.  
You asked the Plan to pay for vision supplies/accessories (V2797) and sales tax (S9999). You say that you did 
not realize that you had to submit just the $130 that you are entitled to. The Plan denied your request. The Plan 
says the services are covered benefits, but the enrollee has exceeded limits set in the subscriber agreement. 
 
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 up to $130 for eyeglasses every 24 months. 
 
We looked at the file and the Plan's rules. The rules say that the Plan pays up to $130 for eyeglasses every 24 
months. The record shows this benefit was exhausted on February 5, 2021. Based on this information, we 
decided that the Plan's rules for coverage of vision supplies/accessories (V2797) and sales tax (S9999)  have 
not been met. Therefore, we decided that the Plan does not have to pay for vision supplies/accessories (V2797) 
and sales tax (S9999) purchased on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a soft tissue graft procedure (D4277) provided on February 
21, 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 a soft 
tissue graft procedure (D4277) provided on February 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits x12 to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy visits x12. You say that you do not agree with the denial 
for physical therapy visits. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits x12 to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), bone graft for repair of peri-implant defect  does not include flap entry and 
closure (D6103), and debridement and osseous contouring of a peri-implant defect or defects surrounding a 
single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure 
(D6102) provided on March 20, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D4265, D6103 and D6102. You say that 
the dental procedures are to save a failing existing dental implant and crown. You also say that if alternate 
codes are needed to let you or the provider know so you can appropriately re-submit the claim. 
 The Plan denied your request. The Plan says you were not enrolled in any sort of supplemental dental plan that 
might furnish you with the additional benefits. According to the EOC for your plan, bone grafts are only 
covered at the time that a tooth is extracted or an implant is placed, while osseous contouring is not covered at 
all. You did not have an implant placed at time of service therefore you were not eligible for coverage for either 
of these services. 
 
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 biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265), bone graft for repair of peri-implant 
defect  does not include flap entry and closure (D6103), and debridement and osseous contouring of a peri-
implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant 
surfaces, including flap entry and closure (D6102) provided on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and immediate 
denture - mandibular (D5140) provided on March 8, 2023 
 
You asked the Plan to pay for the immediate denture - maxillary and immediate denture - mandibular. You say 
that you called prior to the date of service and confirmed dentures were covered.  The Plan denied your request. 
The Plan says these services are not covered under your 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 immediate denture - maxillary 
(D5130), and immediate denture - mandibular (D5140)  are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and 
immediate denture - mandibular (D5140) provided on March 8, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic 
radiographic image (D0330), and the complete lower denture (D5120) provided on March 8, 2023. 
 
You asked the Plan to pay for the dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the items/services provided 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 the comprehensive oral evaluation (D0150), 
panoramic radiographic image (D0330), and the complete lower denture (D5120) provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on January 26, 2023. 
 
You asked the Plan to pay for home evaluation visit. You say that the records attached support the services 
provided. 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 home evaluation visit 
provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on March 20, 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 charges. 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. 
 
 
 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 periodic oral evaluation and cleaning 
(D0120, D1110) provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on November 
05, 2022, to November 19, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. 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 visits provided on November 05, 2022, to November 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on April 12, 2022, to May 
11, 2022. 
 
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 NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 12, 2022. The NOA was not received by the Plan until May 13, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided on 
April 12, 2022, to May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0151, G0152, G0157, G0158, 
G0299, Q5001) provided on July 16, 2022, to August 14, 2022. 
 
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 NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 16, 2022. The NOA was not received by the Plan until November 09, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
(G0151, G0152, G0157, G0158, G0299, Q5001) provided on July 16, 2022, to August 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 25, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the ambulance transport was unrelated to 
the hospice care. 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 ambulance services provided on February 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse a commode chair and sales tax (E0163, S9999) provided 
on February 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse the commode chair and sales tax. You say that the services should be 
reimbursed as you disagree with the charges. The Plan denied your request. The Plan says the items denied 
correctly as they were received by a provider who does not work with Medicare. 
 
 
 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 reimburse a 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 reimburse these items/services. 
Therefore, we decided that the Plan does not have to reimburse a commode chair and sales tax (E0163, S9999) 
provided on February 22, 2023, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have not tried and failed the 
Plan's required drug, intravenous (IV) bisphosphonate therapy. The records do not show that the required drug 
would have negative effects or be less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on January 
2, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you found out that the 
home, that your spouse is in, has been billing for physical therapy. You say that he is not even receiving 
physical therapy so you should not have to pay for the billed amount. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $20 copayment per day for therapy visits. 
 
  The enrollee has been asked to pay a total of $400 for physical therapy visits ($20/visit x 20 visits - $400). 
Physical therapy falls within the outpatient rehabilitation services benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for physical therapy visits provided on January 2, 2023, to January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the submitted medical records support the need for 
IRF admission.  The Plan denied your request. The Plan says based on the available clinical information, we 
have determined that the enrollee's status does not meet medical necessity severity or intensity criteria for acute 
IRF admission. 
 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for knee replacement surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and extractions, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) provided on June 17, 2020. 
 
You asked the Plan to pay for the immediate denture - maxillary and extractions. You say that your servicing 
agent passed away and you didnt know how to file your claim. The Plan denied your request. The Plan says 
the claim was untimely, and the submission did not meet the exception criteria guidelines. 
 
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 immediate denture - maxillary and extractions was not filed until March 
29, 2023. 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 an immediate denture - maxillary (D5130), 
and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on June 17, 2020.