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

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4, 5, 12, and 30 and 
retainer crowns (D6750) for tooth #'s 3, 6, 11, 13, 29, and 31. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need bridges because you 
are missing more than 10 teeth, and you are having trouble eating. The Plan denied your request. The Plan says 
the services are not medically necessary. 
 
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 the pontics 
and retainer crowns 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 the pontics and retainer crowns. Our 
reviewer says that the services are do not meet coverage criteria. Our physician reviewer found the replacement 
of the missing posterior teeth with fixed bridges do not meet the criteria for coverage. Our reviewer also found 
that fixed bridges are only considered for coverage for replacement of anterior teeth according to the Plan. 
 
 
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 the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4, 5, 12, and 30 and retainer crowns 
(D6750) for tooth #'s 3, 6, 11, 13, 29, and 31.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for cardiovascular genetic testing provided on May 2, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is 
not covered. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering provider was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. This testing is not excluded from Medicare coverage. Without this information, 
we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not 
shown that its decision to deny payment for testing is correct or justified by Medicare rules. Therefore, we 
decided that the Plan has to pay for cardiovascular genetic testing provided on May 2, 2020.   
 
 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on June 2, 
2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you have very dense breast 
tissue that makes reading a mammogram difficult.  You say that because of this, a breast ultrasound is 
medically necessary. You also stated that in NY, the governor signed a law stating that this should be covered 
at no cost. The Plan denied your request. The Plan says you were charged this copayment correctly. The plan 
also states that because the allowed amount is less than your copayment obligation, you are responsible for the 
full amount. 
 
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 $160 
copayment for Medicare-covered radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $160 copayment for the breast ultrasound. The breast ultrasound falls within the 
Medicare-covered radiological diagnostic 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. Please note that the NY law you are referring to explicitly states 
that Medicare Advantage Plans, such as the Plan here, are not subject to this law. Therefore, we decided that 
the Plan does not have to waive the copayment for the breast ultrasound you had on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular and maxillary partial denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The contract rules say that 
dentures are covered once every five years. 
 
The file shows that dentures were last received less than five years ago on June 18, 2020. The dentist's office is 
willing to assist you in fixing your current dentures. Based on this information, we decided that the Plan's rules 
for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-
approve a mandibular and maxillary partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that you would like reconsideration 
because your sofa is low and you are unable to stand up from it. The Plan denied your request. The Plan says 
you are able to stand from a chair. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 seat lift mechanism. Our reviewer 
says that based on the medical records provided there is no documentation that the enrollee meets the Local 
Coverage Determination (LCD) criteria for coverage for the requested seat lift mechanism. Our physician 
reviewer found there is no documentation in the provided records that the enrollee is incapable of standing up 
from a regular armchair or any chair in her home. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the seat lift mechanism.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises and therapeutic activities provided 
on November 29, 2019, and December 10, 2019 by an OON provider. 
 
You asked the Plan to pay for the therapeutic exercises and therapeutic activities. The Plan denied your request. 
The Plan says the services were rendered by a non-participating provider. The Plan also says that the enrollee 
self-referred to the non-participating provider for 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 has network providers 
available who can provide 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 therapeutic exercises and therapeutic activities 
provided on November 29, 2019, and December 10, 2019 by an OON provider.
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 your niece is not equipped to take care of you, and 
needs help. You also say that you are unable to regain maximum function. The Plan denied your request. The 
Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you do not require the intensity of services provided at an IRF. Our reviewer found 
that specifically, you have not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our physician reviewer also found that your care needs can be met at a lower 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET (78815). 
 
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because the PET is 
medically necessary. The Plan denied your request. The Plan says the requested study is not supported for the 
first staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET. Our reviewer says that the 
member does not have an indication for which a PET Scan can be covered. Our physician reviewer found 
initial staging for prostate cancer is not a covered indication. 
 
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 PET have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an EGD provided on March 17, 2020. 
 
You asked the Plan to pay for the EGD. The Plan denied your request. The Plan says non-emergent, non-urgent 
services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an EGD provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for infrared heat treatment (97026) provided. 
 
You asked the Plan to hold you harmless for the infrared heat treatment. You say that you would like 
reconsideration because these services were rendered by an in-network provider. The Plan denied your request. 
The Plan says that this service is not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the infrared heat treatment by a contract provider. The file does not show that the Plan 
provided notice that the infrared heat treatment would not be covered. Under Medicare rules, this means the 
infrared heat treatment is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for infrared heat treatment (97026) provided.  
 
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 pre-approve a crown (D2740) for tooth #9. 
 
You asked the Plan to pre-approve the crown. You say that the enrollee needs the crown on tooth #9 replaced 
because there is an open mesial margin. The Plan denied your request. The Plan says the documentation does 
not demonstrate the need for replacement of the existing crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the 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 the crown. Our reviewer says that the 
crown does not meet coverage criteria. Our physician reviewer found the documentation indicates that there is 
an open margin. Our reviewer found that there was no indication of active caries or if the defective margin 
could be repaired. Our physician reviewer also found that documentation provided does not meet the criteria 
for coverage for a replacement crown for tooth #9. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #9.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 28230 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the surgical services rendered on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213), ultrasound measurement 
of bladder capacity (51798), manual urinalysis test with examination using microscope (81000) and electronic 
assessment of bladder emptying (51741) provided on September 25, 2018 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for office outpatient visit, ultrasound measurement of bladder capacity, manual 
urinalysis test with examination using microscope and electronic assessment of bladder emptying. You say that 
You say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. The record 
did not contain documentation of a referral from the primary care physician. 
 
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 has network providers 
available who can provide 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 outpatient visit (99213), ultrasound 
measurement of bladder capacity (51798), manual urinalysis test with examination using microscope (81000) 
and electronic assessment of bladder emptying (51741) provided on September 25, 2018 by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate lower denture (D5140) provided on June 22, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you had ulcerative colitis. You say that as a 
result, your teeth are rotten and breaking off. You also say that the dentist recommended you get your teeth 
removed and get dentures. The Plan denied your request. The Plan says immediate lower denture is not listed 
as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 
immediate lower denture (D5140) provided on June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan provided on 
February 17, 2020. 
 
You asked the Plan to pay for PET scan. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because this test was not billed with an acceptable 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are only covered when billed with 
certain, specific diagnosis codes.  
 
We looked at the file and Medicare rules. This test was not billed with a covered diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan provided on 
February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you checked out of the 
hospital the same day but are being billed for a full day. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $195 
copayment for each day for days 1-7 per admission for Medicare-covered inpatient hospital care.  
 
You have been asked to pay a $195 copayment for a 1-day inpatient hospital stay. An inpatient hospital stay 
falls within the "Inpatient Hospital 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 inpatient hospital stay.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection (64636 x1). 
 
You asked the Plan to pre-approve the injection. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the number of injections requested exceeds the amount allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two (2) joints bilaterally thermal 
RF sessions will be reimbursed in any calendar year. 
 
We looked at the file and Medicare rules. The record shows three different joints were requested. Two have 
already been approved. The request exceeds the amount of joints that can be covered in any calendar year. 
Based on this information, we decided that Medicare rules for coverage of the injection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a facet joint injection (64636 x1).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the stomach (74183). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says a Computed Tomography Scan would be 
more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically necessary or reasonable. Our physician reviewer found there is no 
documentation provided requiring the requested MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the stomach (74183).