Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility services provided from 
January 31, 2023, to March 1, 2023. 
 
You asked the Plan to pay for the continued skilled nursing facility services. You say that the services should 
be covered under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 100-day SNF 
benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from June 29, 2022, to 
January 30, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the continued skilled nursing facility services provided from January 31, 
2023, to March 1, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provider services provided on September 30, 2022. 
 
You asked the Plan to pay for the provider services. You say that you are requesting reconsideration of the 
denied claim. 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 the provider services 
provided on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 28, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the doctor provided service to the member in 
good faith and should be reimbursed for the services. The Plan denied your request. The Plan says out-of-
network virtual care is not covered. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network.  
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services 
out-of-network. Based on this information, we decided that the Plans rules for coverage of the telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 18, 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 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 December 9, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 18, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for decoronation or submergence of an erupted tooth (D3921) 
provided on June 7, 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 
decoronation or submergence of an erupted tooth (D3921) provided on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 13, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 office visit provided on March 13, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided on May 2, 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 intraoral 
x-rays (D0220, D0230) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on March 20, 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 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 items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for endodontic therapy (D3330) provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multifocal lens cataract surgery provided October 20, 2022, 
to April 13, 2023. 
 
You asked the Plan to pay for a non-conventional intraocular lens. You say that you can see a lot better now 
that you have had the surgery. The Plan denied your request. The Plan says the surgery provided is not a 
covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 non-conventional intraocular lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for a multifocal lens cataract surgery provided October 20, 2022, to April 13, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the peripheral nerve injections, and the 
ultrasonic guidance for needle placement provided by an in-network provider on February 24, 2023. 
 
You asked the Plan to waive the cost sharing for the nerve injections, and the ultrasonic guidance. You say that 
you do not want to pay the cost share. 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. Your 
contract with the Plan says that there is a $1000 deductible, and that you must pay a $250 copayment, after 
your $1,000 plan deductible, for each in-network Medicarecovered outpatient surgery at an ambulatory 
surgical center. 
 You have been asked to pay a $34.91 deductible for the ultrasonic guidance. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have been asked to pay a 
$965.09 deductible for the nerve injections ($228.36 + $736.73 = $965.09). You have also been asked to pay a 
$182.40 copayment for one of the nerve injections because the Plan is only holding you responsible for this 
amount which is less than the $250 copayment. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $1000 deductible which applies to outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers, and outpatient diagnostic tests and therapeutic 
services and supplies. This cost sharing is a contractual obligation that had not been met at the time the nerve 
injections, and the ultrasonic guidance were received on February 24, 2023. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the peripheral nerve injections, and the ultrasonic guidance for 
needle placement provided by an in-network provider on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluations (D0180) provided on 
April 25, 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 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 January 19, 2023, and 
February 28, 2023. Therefore, we decided that the Plan does not have to pay for comprehensive periodontal 
evaluations (D0180) provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on March 21, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
fall within your plan benefits. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on January 2, 2023, to January 
30, 2023, by an OON provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 psychotherapy provided on January 2, 2023, to 
January 30, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), an abutment 
supported crown (D6058), and a periodic oral evaluation (D0120), provided on May 24, 2023. 
 
You asked the Plan to pay for D6057, D6058, and D0120. You say that you know implants are not covered, but 
you cannot find where crowns are not covered. The Plan denied your request. The Plan says these services have 
been processed correctly. 
 
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), an abutment supported crown (D6058). A $25 copayment has been correctly 
applied to a periodic oral evaluation (D0120), provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on February 14, 
2023. 
 
You asked the Plan to pay for the chiropractic office visit. You say that the provider has a Doctor of 
Chiropractic and a postdoctoral education in Functional Medicine. You say he specializes in customizing health 
programs. The Plan denied your request. The Plan says the service is not covered when billed by a chiropractor. 
 
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 office visit provided by a chiropractor on February 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service January 21, 2023. 
 
You asked the Plan to pay for the billed services. You say that the date of service should be the date of 
performance. The Plan denied your request. The Plan says that an incorrect date of service was billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. Molecular pathology tests performed by a laboratory requires that the DOS 
be reported as the date the testing was performed under certain circumstances. The Plan has not shown that the 
lab has not met one of the exceptions to the date of service guidelines. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the lab testing billed for date of service January 21, 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the home health aide services requested 
are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have currently documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. You also say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause of the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by your dentist 
on May 5, 2023. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this service is only covered when provided by an oral surgeon. 
 
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 limited 
oral evaluation (D0140) provided by your dentist on May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trilogy Ventilator (E0466). 
 
You asked the Plan to pre-approve a Trilogy Ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 Trilogy Ventilator. Our reviewer says 
that you do not need this item. Our physician reviewer found there is no diagnosis of thoracic restrictive disease 
or neuromuscular disease. Medicare does not cover a home ventilator for the treatment of obstructive sleep 
apnea. 
 
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 Trilogy Ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Trilogy Ventilator (E0466).