Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home based palliative care services. 
 
You asked the Plan to pre-approve the home based palliative care services.. You say that the services are 
medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested services are not a covered benefit. 
The plan provides supplemental coverage for these services. The plan's rules apply in this case. The plan's rules 
state that these services are covered when members are terminally ill with a life expectancy of 7-12 months. 
 
We looked at the file, the plan's rules, and Medicare rules. The documentation provided does not show that the 
enrollee has a terminal diagnosis. Based on this information, we decided that the plan's rules for coverage of 
the home based palliative care services. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home based palliative care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recliner chair provided on July 29, 2020. 
 
You asked the Plan to pay for the services provided. You say that the plan pays 80% of the cost for items 
needed to maintain your health. The Plan denied your request. The Plan says the provider is not a Medicare-
approved or authorized provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that no 
provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider 
or supplier is enrolled in the Medicare program. 
 
The provider in this case is not eligible to provide services under Original Medicare. The Plan did not pre-
approve the item 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 recliner chair provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two preventive procedures, two bone replacement grafts 
for ridge preservation, comprehensive oral evaluation, two extractions, two endosteal implants, and guided 
tissue regeneration provided on June 22, 2020, and June 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have had extensive dental work done, and it 
is costly for you. The Plan denied your request. The Plan says the preventive procedures are excluded from 
coverage. The Plan also says that you have already received the maximum amount of coverage allowed. 
 
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, unspecified preventive procedure is not 
among those covered under this benefit. The Plan also offers a $400 allowance every year for Non--Medicare 
covered preventive dental services and Non-Medicare covered comprehensive dental services combined. The 
contract says that you are responsible for any amount above the dental coverage limit. The record shows that 
you met the annual maximum benefit while processing the claim for the June 22, 2020 date of service, and your 
annual allowance has been exhausted.  
 
Therefore, we decided that the Plan does not have to pay for the two preventive procedures, two bone 
replacement grafts for ridge preservation, comprehensive oral evaluation, two extractions, two endosteal 
implants, and guided tissue regeneration provided on June 22, 2020, and June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the specialist office visit provided on September 
16, 2020. 
 
You asked the Plan to waive the copay for the specialist visit. You say that you were advised by the provider 
that the copay would be $10. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copay per visit from a specialist.  
 
You have been asked to pay a $40 copay for the specialist visit. The service falls within the physician services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copay for the specialist office visit provided on 
September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy provided on May 26, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the endodontic therapy. You say that you would like a full reimbursement 
because it was the Plan's fault that you went to an OON provider. The Plan denied your request. The Plan says 
the service was rendered by a non-participating provider, and you were referred by another non-participating 
provider. The Plan also says that you contacted the Plan prior to the service being rendered, and were given a 
participating provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy provided on May 26, 2020 by an OON provider.  
 
Your complaint about possibly being given inaccurate information by the Plan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 23, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on January 23, 2020 by an out 
of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not 
require any skilled nursing or rehab services on a daily basis. The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 6, 2020 by an out of 
network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 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 medical services provided on August 6, 2020 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. The enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in the home with home health services or in a long-term care facility on a part 
time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit (99203) and wrist x-ray (73110) provided. 
You say that you would like reconsideration because you did not want to go to the emergency room due to 
COVID concerns and this provider said they could render all necessary services. The Plan denied your request. 
The Plan says you do not have out-of-network benefits. 
 
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 medical services provided by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits with an orthopedic 
surgeon and x-rays you had
 
You asked the Plan to waive the copayments for the office visits and x-rays. You say that you don't think you 
should have to pay these copayments since all of your care could have been provided in one visit. The Plan 
denied your request. The Plan says you were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for specialist visits and a $30 copayment for x-rays.  
 
You have been asked to pay a $45 copayment for each of the office visits and a $30 for each of the x-rays. 
These copayments apply regardless of the reason for the services. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for the office visits with an orthopedic surgeon and x-rays you had.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99213) provided on June 12, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not emergent. There were network 
providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 the physician services (99213) provided on June 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 16, 
2020, to February 18, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the record clearly reflects that the 
enrollee required over two midnights of care. The Plan denied your request. The Plan says the services could 
have been rendered at lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not meet admission criteria. A lower level of care, even extended 
observation would have been more appropriate. Denial upheld 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 16, 2020, to February 
18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with COVID-19. The enrollee is 
intubated/ventilated. The enrollee has not yet received a tracheotomy and remains critically ill. Weaning is not 
yet in progress.  There is no evidence that the enrollee requires services that are not currently available in the 
acute care hospital setting. Therefore, the enrollee does not meet criteria for the requested LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided. 
 
You asked the Plan to pay for the services provided. You say that your heart was racing, and you could not 
drive yourself. The Plan denied your request. The Plan says your coverage does not provide for this service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee needed this service and you 
feel you should not owe anything. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 11, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this additional help at home. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the interrogation device evaluation 
provided. 
 
You asked the Plan to waive the copayment for the interrogation device evaluation. You say that your heart 
monitoring device was supposed to stop working. The Plan denied your request. The Plan says 
the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for a specialty care physician. Covered services include consultation, diagnosis, and treatment by a 
specialist.  
 
You have been asked to pay $26.54, which is less than the standard $40 copayment for the interrogation device 
evaluation. The interrogation device evaluation falls within the "Physician/Practitioner services, including 
doctor?s office visits" 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 the 
interrogation device evaluation provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services provided on August 3, 2020. 
 
You asked the Plan to pay for the services provided. You say that you were having trouble with noise. The Plan 
denied your request. The Plan says the provider is not a network vendor with the plan. 
 
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 plan?s coverage rules apply in this case.  
 
We looked at the file, and the Plan's rules. The documentation shows that you received services from a non-
preferred vendor. Based on this information, we decided that the Plan's rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aid services provided on August 3, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine 5% patch (J3490). 
 
You asked the Plan to pre-approve the Lidocaine patches. You say that the patches are medically necessary. 
The Plan denied your request. The Plan says this item is not covered under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine 5% patch 
(J3490).  
 
Benefits for the Lidocaine patches may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.