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

 
We decided that the Plan does not have to pre-approve MRI of breast including computer-aided detection. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this MRI is not routinely indicated in individuals with breast pain and a negative 
evaluation. 
 
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 reasonable or necessary. Our physician reviewer found you have no 
documented increased risk of breast malignancy such as BRCA etc. The mammogram revealed no mass etc. 
and the description of the breast tissue as scattered glandular elements revealed no significant limitation of 
mammography such as extremely dense tissue. Also, the negative targeted ultrasound is very pertinent and at 
the time of the exams no nipple inversion or discharge was described. MRI is reserved if there are equivocal 
imaging findings or if there is a greater than 20% lifetime risk of breast cancer which do not apply in this case. 
If repeat clinical exam reveals a persistent nodule in either or both breasts repeat ultrasound would be indicated 
followed by consideration of biopsy rather than 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 breast including computer-aided detection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) and intraoral periapical X-ray (D0220) received on September 25, 2020, and osseous surgery (D4261) and occlusal adjustment (D9951) received on October 14, 2020.

You asked the Plan to pay for periodontal maintenance, intraoral periapical X-ray, osseous surgery, and occlusal adjustment. You say that you could not get a list of specifics by telephone from the Plan as to what is covered and what is not. The Plan denied your request. The Plan says rules for payment have not been met.

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 periodontal maintenance (D4910) and intraoral periapical X-ray (D0220) received on September 25, 2020, and osseous surgery (D4261) and occlusal adjustment (D9951) received on October 14, 2020. 

Your complaint about not receiving clear information from the Plan about your dental benefit 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for tooth 
#22 and #27. 
 
You asked the Plan to pre-approve the services. You say that you have difficulty eating appropriately with your 
dentures. 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. 
 
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 pre-approve 
surgical placement of implant body (D6010) for tooth #22 and #27.
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 requires no nursing services which would be considered 
skilled services by Medicare. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the claim was submitted with a laboratory 
place of service code, but the record indicates that the face-to-face encounter took place in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 3, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 days sensor for the enrollee. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare cannot cover this device for convenience alone. 
 
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 sensor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's treatment does not require frequent adjustment on the basis of testing results. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre 14 days sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
August 24, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the 
charges because a previous claim for the same thing was overturned in your favor. The Plan denied your 
request. The Plan says the claims were processed correctly, and you are being charged the correct 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on August 24, 2020. The allowed amount is $1,194 and 20% of that is 
$238.80.  
 
You have been asked to pay the total coinsurance amount of $238.80 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric services provided on August 12, 2019. 
 
You asked the Plan to pay for the psychiatric services. You say that you did not receive proper notice of the 
enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely. 
 
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 psychiatric services was not filed until September 10, 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 psychiatric services provided on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the specialist services rendered on 
September 24, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you had to go to this provider 
because you were out of options. The Plan denied your request. The Plan says the coinsurance was 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% 
coinsurance for services obtained from an out-of-network specialist.  
 
Review of the file shows that you received services from an out-of-network specialist on September 24, 2020.  
You have been asked to pay a 40% coinsurance for these services. These services fall within the services 
obtained from an out-of-network 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 coinsurance 
for the specialist services rendered on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic tests provided on March 5, 2020. 
 
You asked the Plan to waive the copayment for diagnostic tests. You say that you disagree with the charges 
because you were not informed that you would owe a copayment. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 $75 
copayment for non-radiologic diagnostic procedures and tests.  
 
You have been asked to pay the allowed amount of $22.75, which is less than the $75 copayment for diagnostic 
tests. Diagnostic tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic tests provided on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the medication will help the enrollee's bones to 
become stronger. The Plan denied your request. The Plan says the drug is not FDA-approved for the treatment 
of osteoporosis in males. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis of the hip. Evenity was requested to be initiated prior to starting a 
bisphosphonate or Prolia. Evenity is not currently FDA-approved for use in male osteoporosis. Current 
evidence found in the approved compendia also do not sufficiently support use of this medication in this 
clinical situation. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 20 additional routine transports. 
 
You asked the Plan to approve these services. You say that this is your only means of transportation. The Plan 
denied your request. The Plan says the services exceed the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 15 of 
the 20 total one-way trips allowed by your supplemental benefit. Once you have used all 20 one-way trips, 
further trips are not covered by Medicare or your supplemental benefit. Therefore, we decided that the Plan 
does not have to approve 20 additional routine transports.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology screening procedures provided on September 
30, 2020. 
 
You asked the Plan to pay for the cytopathology screening procedures. The Plan denied your request. The Plan 
says 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 Plan says that the Plan has also determined that these services are 
not urgent or emergent, nor were they 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 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 cytopathology screening procedures provided on September 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on October 7, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 file shows that you received an oral exam (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), 
and cleaning (D1110), from an out-of-network provider. You were charged a 50% coinsurance for these 
services.   
 
The file shows that you received two intraoral x-rays on the date of service at issue. We looked at the file, and 
Medicare rules. Your plan only covers one intraoral x-ray per calendar year. 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 further pay for the dental services provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 8, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because this was a phone visit. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct 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 $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and humidifier. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a CPAP device is covered when specific criteria 
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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted compliance reports show 
that you are not using the CPAP enough for it to be effective. You do not meet the Medicare requirement of at 
least four hours per day for at least 70 percent of the days. The records do not indicate any plans to address the 
compliance issue. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device and humidifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. You say that the enrollee needs these injections in 
order to treat her pain. The Plan denied your request. The Plan says the requested treatment is not shown to be 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SI joint injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a female with chronic low back pain. She takes Soma, Norco, and Valium for 
pain. SI joint diagnostic loading tests are not detailed in the physical exam. There is a deficiency in 
documentation of the physical exam, and the patient has not participated in Physical Therapy. Therefore, the 
request is deemed not medically reasonable or 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 the SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee wants to continue care with the 
provider. The Plan denied your request. The Plan says the services can be performed by community level 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve oncology 
services to be provided by an out-of-network (OON) provider.