Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 11, 2019, to July 14, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible for this inpatient stay. The Plan denied your request. The Plan says the correct copayment has been 
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 $360 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $360 copayment per day for days 1-2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $72- ($360 x 2 days = $720). 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 provided by a participating provider on July 11, 2019, to July 14, 2020.  
 
We note your complaint about the issues with the surgery. Your complaint is a grievance that must be answered 
by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee has tried and 
failed 2 standard pumps and needs this device to control her condition. The Plan denied your request. The Plan 
says the denial of authorization for this item is correct, because the records do now indicate how long ago a 
basic pump was tried or how long the enrollee was treated for with a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants.

You asked the Plan to pre-approve the endosteal implants. You say that you need these services to treat a medical condition. The Plan denied your request. The Plan says neither Medicare nor your health plan covers this item.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve 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. The service you requested is dental in nature. Therefore, we decided that the Plan does not have to pre-approve endosteal implants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 26, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records show the enrollee had molecular pathology testing on May 26, 2020.  The 
denial remains upheld as non-covered services because Medicare denies coverage when a laboratory assays 
two or more genes in a patient in parallel.  Those two or more genes will be considered part of the same panel.  
A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as submitted 
because the services provided would only be paid under a single code. Medicare rules for coverage of this 
service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided 
to the enrollee on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve nerve treatment on bicuspid tooth (D3320). 
 
You asked the Plan to pre-approve nerve treatment on bicuspid tooth. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that the service 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 Plan covers one 
endodontic therapy per tooth per one lifetime. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of nerve treatment on bicuspid tooth have been met. Specifically, there is no indication you have 
exhausted your one endodontic therapy per tooth per lifetime. This means the service requested is a covered 
benefit. Therefore, we decided that the Plan has to pre-approve nerve treatment on bicuspid tooth (D3320).  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up of portable x-ray equipment coded Q0092 and the 
transportation of portable x-ray equipment coded R0070 provided on June 29, 2020. 
 
You asked the Plan to pay for the set-up and transportation of portable x-ray equipment. 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 payable. 
 
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 codes Q0092 and R0070 are not supported in the medical record. Specifically, these services 
were billed with place of service 31 (skilled nursing facility). However, the inpatient nursing services being 
received by the enrollee were a non-covered stay. Therefore, these services should be billed with place of 
service 32 (nursing facility). Based on this information, we decided that Medicare rules for coverage of the set -
up and transportation of portable x-ray equipment have not been met. Therefore, we decided that the Plan does 
not have to pay for the set-up of portable x-ray equipment coded Q0092 and the transportation of portable x-ray 
equipment coded R0070 provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on September 
14, 2020. 
 
You asked the Plan to pay for the therapeutic pulpotomy. You say that you assumed this was a covered service. 
The Plan denied your request. The Plan says these services are not covered under the supplemental 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. 
 
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 
therapeutic pulpotomy (D3220) provided on September 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide non-emergency transport taxi. 
 
You asked the Plan to provide non-emergency transport taxi. You say that you are wheelchair bound after 
having your fourth spinal surgery. The Plan denied your request. The Plan says you do not have a 
transportation benefit available as a supplemental benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transport taxi have not been met. Therefore, we decided 
that the Plan does not have to provide non-emergency transport taxi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need these foot orthotics due to your 
conditions. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued services to a skilled nursing facility (SNF) 
beyond 12/17/20 for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says care can be received in another setting. 
 
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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation of a 
requirement for skilled nursing or skilled therapy services after 12/17/20. There is no documentation that the 
enrollee required services on an inpatient basis, in a skilled nursing facility setting after 12/17/20. 
 
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 continued services to a skilled nursing facility (SNF) beyond 12/17/20 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no pre-post measurements over four weeks to support a good faith trial with 
the basic pump before the request for an advanced pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that this enrollee has lymphedema of the chest, trunk, or abdomen. 
The enrollee does not have unique characteristics that would indicate the segmented pump over a standard 
pump. There is no documentation of a four week trial and failure of the standard pump with pre and post 
measurements. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services you received on August 26, 
2020. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says there is a $200 allowance for 
supplemental comprehensive dental services, which includes fillings and simple tooth extractions every year. 
The Plan says that you received a filling on tooth number 10 on March 5, 2020. The Plan says they paid $179 
for this service, leaving $21 remaining of your $200 annual allowance for these services. The Plan says the 
claim for the services you received on August 26, 2020, the Plan paid the remaining $21 toward the $179 cost 
of a filling on tooth number 7, which depletes your allowance and leaves you with a cost share of $158. The 
Plan says, in addition, the claim for the services you received on August 26, 2020 indicates you received a 
filling on tooth number 28, therefore, since the Plan paid your annual $200 benefit allowance, the cost of this 
service, $162, is your responsibility. 
 
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. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows the Plan paid your $200 allowance 
for dental services for the year. Since, the Plan paid your annual $200 benefit allowance, you are responsible 
for the remaining cost of $320 total for the dental services you received on August 26, 2020. Therefore, we 
decided that the Plan does not have to pay additionally for the dental services you received on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for COVID-19. The patient is not 
intubated/ventilated. There is no evidence that the patient 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 
patient to the LTACH. The patient can remain at the current ACH until such time no acute services are 
required.  The patient can then be transferred/discharged to a lower level of care for any ongoing LTC 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this doctor is a liar and 
you never saw him on this date. The Plan denied your request. The Plan says the correct copayment has been 
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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on February 19, 2020.  
 
Your grievance about not seeing the doctor is being handled separately by the Plan. Medicare does not allow us to make 
decisions based on grievances.
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 records show that the enrollee has not completed the full 
course of care in the hospital. 
 
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 an intraabdominal abscess, complicated 
by pleural effusions and renal failure requiring the initiation of hemodialysis. The enrollee was transiently 
intubated/ventilated, but is no longer intubated/ventilated. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray 
(D0220), and the unspecified preventive service (D1999) provided on August 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services you received were necessary for 
treatment. You also say that you would like an updated Schedule of Benefits to include these and other items in 
the current year. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a 
covered service. The Plan says the unspecified preventive service is not listed as a covered service. The Plan 
says 1 periapical x-ray per calendar year is covered. The Plan also says that the frequency limit for this service 
has been exceeded. 
 
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 limited oral evaluation and 
unspecified preventive service are not among those covered under this benefit. Additionally, the frequency 
limit of 1 periapical x-ray per calendar year has been exceeded. The record shows that the Plan paid for a 
periapical x-ray that you received on March 10, 2020. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the unspecified preventive service 
(D1999) provided on August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary 
osteoarthritis of the right knee. She has not tried and failed the Plan's required drugs of Orthovisc and 
Monovisc. The records do not show that the required drugs would be contraindicated or less effective; 
therefore, Gelsyn is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn.