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

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a fixed retainer provided on July 
23, 2020 by an OON provider. 
 
You asked the Plan to pay for the re-cement or re-bond of a fixed retainer. You say that you contacted the plan 
prior to receiving this service, and were told that the service would be covered since it was a permanent 
retainer. You also say that you would like to receive the $75.00 you paid back, because you were given 
incorrect information. The Plan denied your request. The Plan says the coinsurance amount you are being 
charged is correct. The Plan also says that you were advised of your coverage, and were also told that the 
benefit does not advise that retainers are covered. 
 
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, you are responsible for a 50% 
coinsurance for services rendered by an OON provider. The record shows that when you contacted the Plan 
you were advised of your coverage, and were also told that the benefit does not advise that retainers are 
covered. The record also shows that during your call, you did not ask if the provider you wanted to see was in-
network or OON. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of a 
fixed retainer provided on July 23, 2020 by an OON provider.  
 
Your complaint about possibly being misinformed 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 3, 
2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not include a critical care visit of 30-74 minutes that was performed on the billed date of service. The 
documentation does not include the time spent providing the service. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services coded 99291 provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent 150 MG/ML pen. 
 
You asked the Plan to pre-approve Praluent 150 MG/ML pen. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Praluent 150 MG/ML pen.  
 
Benefits for Praluent 150 MG/ML pen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share charged for ambulance transport provided to the 
enrollee on January 10, 2020. 
 
You asked the Plan to waive this cost share. You say that this transport should be covered by the Plan because 
the enrollee could not ride in a regular vehicle due to the oxygen she uses. The Plan denied your request. The 
Plan says this cost share was applied based on the Plan contract agreement and the services provided. The Plan 
notes the provider waived the mileage charged and only the copayment of $233.80 remains.  
 
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 contract with the Plan clearly says that you must pay a $300 
copayment for each ambulance transport. In this case the enrollee is actually being asked to pay less than the 
normal contractual payment. 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 when they enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share charged for ambulance transport 
provided to the enrollee on January 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the ambulance transportation services provided 
on June 27, 2020. 
 
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says 
the claim was adjusted 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 $250 
copay per ground ambulance transport.  
 
You have been asked to pay $212.59 for the services provided. Because the amount is less than the $250 copay, 
you were charged the lesser amount. The services fall within the ambulance 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 ambulance transportation services provided on June 27, 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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to LTACH. 
 
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. You are 
currently undergoing treatment at an acute care hospital (ACH), having initially been admitted with renal 
failure, bradycardia ad an upper gastrointestinal bleed. You subsequently tested positive for COViD-19. You 
are not intubated/ventilated. There is no evidence that you require services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to 
the LTACH. You can remain at the current ACH until such time no acute services are required. You can then 
be transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer 
found that your condition does not meet Medicare criteria for 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for a hypertensive emergency. The enrollee 
was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from the 
ventilator. Whether the enrollee will achieve significant enough neurologic recovery to be decannulated is 
unclear. There is no evidence that the enrollee requires services that are not currently available. As LTACHs 
and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to 
the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 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 the medical services provided to the enrollee by an out-of-network provider 
on August 19, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve seven additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the additional OT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says that six visits have been approved. More visits are not 
medically necessary. The enrollee's feeding will improve with practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional OT visits. Our reviewer 
says that the requested additional OT services are medically necessary. Our physician reviewer found the 
record shows that tube feedings are being cut back to encourage more oral feeding. The potential benefit from 
the enrollee becoming independent in feeding is an important goal. Additional sessions to allow the enrollee to 
become independent in feeding is 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 the additional OT visits have been met. Therefore, we decided that the Plan has 
to pre-approve seven additional occupational therapy (OT) visits.  
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transradial prosthesis and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information that another body-powered prosthesis will not work. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the treating medical practitioner progress note documentation does not support that you require a 
myoelectric prosthesis over a body powered prosthesis. The treating medical practitioner progress reports do 
not reveal that the body powered prosthesis is unable to effectively meet your 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transradial prosthesis and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve separate payment for MIRCERA for the enrollee. 
 
You asked the Plan to pre-approve separate payment for MIRCERA. You say that the member needs the 
injections for treatment of End Stage Renal Disease. The Plan denied your request. The Plan says that the 
requested medication should be billed to Medicare Part B bundled payment with the Medicare dialysis facility. 
 
The Plan must follow Medicare rules. Medicare rules say that ESRD facilities are responsible for furnishing 
drugs directly or under arrangement.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of MIRCERA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
separate payment for MIRCERA for the enrollee.  
 
Please note: Our determination is the need for separate payment only. We are making no determination as to 
the medical necessity of the requested drug, only that it must be provided by the ESRD facility directly or 
through arrangements and will be included in the composite rate paid to the facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99233) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported unless the evaluation and management services are for unrelated problems.  
 
We looked at the file and Medicare rules. The services in question were provided on the same date of service as 
services rendered by a physician of the same specialty and in the same group practice. Per Medicare rules, the 
requested services are not payable, as only one E&M service is payable in this situation. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (CPT 99233) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from June 21, 2019, to July 5, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until October 21, 2020. 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 the services provided from June 21, 2019, to July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard you received on July 27, 2020. 
 
You asked the Plan to pay for the occlusal guard. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal guard you received 
on July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee 
has lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed to show safety and efficacy. Additionally, there 
is no spinal instability indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member is not shown to have daily skilled nursing needs. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring for localization of cerebral seizure services 
coded 95951. 
 
You asked the Plan to pay for the monitoring services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95951 is not supported in the medical record. Specifically, this code was billed with 
modifier 26. In addition, the documentation submitted indicates that EEG monitoring was done for less than 
twelve hours. There is a more appropriate modifier that should be used to bill for the services provided. Based 
on this information, we decided that Medicare rules for coverage of the monitoring services have not been met. 
Therefore, we decided that the Plan does not have to pay for the monitoring for localization of cerebral seizure 
services coded 95951.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on August 16, 2018. 
 
You asked the Plan to pay for the services provided. You say that the provider performed the services, and 
should be paid accordingly. The Plan denied your request. The Plan says the claim was received past the 
allowed timeframe. 
 
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 services provided was not filed until September 2, 2020. 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 the imaging services provided on August 16, 2018.