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

We decided that the Plan does not have to waive the deductible applied to the office visit you had with a 
physical medicine specialist on August 31, 2020. 
 
You asked the Plan to waive the deductible applied to the specialist visit. You say that your previous visit was a 
telemed visit and you didn't have a copayment.  You said that this doctor no longer does telemed visits, so you 
had to go into the office.  You had no choice but to go into the office, so you shouldn't have to pay for this. The 
Plan denied your request. The Plan says you were assessed this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for medical care.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for 
medical care. This cost sharing is a contractual obligation that had not been met at the time the specialist visit 
was received on August 31, 2020. This cost sharing applies regardless of the reason why you had to go into the 
office for care. Therefore, we decided that the Plan does not have to waive the deductible applied to the office 
visit you had with a physical medicine specialist on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay up to the annual maximum for the abutment supported porcelain fused to 
metal crown and prefabricated abutment provided on October 21, 2019. 
 
You asked the Plan to pay for the abutment supported porcelain fused to metal crown and prefabricated 
abutment. You say that you would like the remaining $689 of your benefit year maximum to be sent to the 
dental provider. You also say that the 2019 EOC does not mention that an alternate procedure of a partial 
denture can be used to substitute for a crown on a dental implant. The Plan denied your request. The Plan says 
that an alternate benefit of a partial was given for your crown. The Plan also says that a partial was already paid 
for as an alternate benefit for an implant crown in the same arch on April 5, 2018. 
 
The rules say a plan must provide you with a clear and accurate description of the Original Medicare and/or 
mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and 
limitations and any other conditions associated with the use or receipt of the benefits. Your contract with the 
Plan does not say in clear and accurate terms that there are alternative benefits for major services. The contract 
also does not clearly state that an implant would be paid as a partial denture, nor that if the implant were paid as 
a partial denture, that another implant would not be covered within 60 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the abutment supported porcelain fused to metal crown and prefabricated abutment have been met. 
You reasonably believed that these services would be covered, as no alternative benefits or limitations are 
listed in the Plan?s 2019 EOC. The contract also clearly states that crowns, bridges, and dentures supported by 
implants are covered benefits. Therefore, we decided that the Plan has to pay up to the annual maximum for the 
abutment supported porcelain fused to metal crown and prefabricated abutment provided on October 21, 2019.  
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 23, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the laboratory services are not supported in the medical record. Specifically, these services should 
be billed with code 81479. In addition, the approved DEX Z-code should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on July 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this extra expense. The Plan 
denied your request. The Plan says these services exceeded your dental benefit coverage limit. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit for services provided on 
January 9, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the dental services provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two periodontal scalings and root planings of one to 
three teeth per quadrant (D4342 x2). 
 
You asked the Plan to pre-approve the scalings and planings. You say that periodontal charting was not done 
because the enrollee is very sensitive, and their gums are inflamed. The Plan denied your request. The Plan 
says this 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. 
 
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 two 
periodontal scalings and root planings of one to three teeth per quadrant (D4342 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's services provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for the surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission for the 
surgery. The Plan denied your request. The Plan says the stay is not necessary. 
 
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 looked at 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. The approved surgical procedure is not on the 
Medicare Inpatient Only List. The member is noted to have no significant uncontrolled chronic conditions that 
pre-operatively would warrant an in-patient level of care. If the member undergoes the procedure and intra- or 
post-operatively requires care that meets an inpatient level of services, then the Plan would approve inpatient 
care as an observation conversion. Therefore, we decided that the Plan does not have to pre-approve inpatient 
admission for the surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you have conditions that prevent you from 
walking. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 records do not show that 
you have a personal mobility deficit that impairs participation in mobility-related activities of daily living 
(MRADLs) in the home. Your mobility needs can be helped by a walker. The records do not support that the 
power scooter will significantly improve your ability to perform MRADLs in the home. 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 power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two implant supported crowns and two custom fabricated 
abutments provided on July 13, 2020. 
 
You asked the Plan to pay for the implant supported crowns and custom fabricated abutments. You say that you 
were told that you had coverage for crowns, and feel these services should be paid. The Plan denied your 
request. The Plan says this service is not covered under your plan. 
 
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 two 
implant supported crowns and two custom fabricated abutments provided on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
lower spinal canal provided on July 14, 2020. 
 
You asked the Plan to waive the copayment for the MRI of lower spinal canal. You say that you would like the 
copayment waived. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $225 
copayment for diagnostic radiology services in the outpatient department.  
 
You have been asked to pay a $225 copayment for the MRI of lower spinal canal. The service provided falls 
within the diagnostic radiology services in the outpatient department 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 magnetic resonance imaging (MRI) of lower spinal canal 
provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you rely on the facility to obtain prior 
authorization. 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 physician services provided on June 12, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the office visit and x-ray provided on July 22, 2020. 
 
You asked the Plan to pay for the physician services. You say that you believe the services you received should 
be covered. You say that the services were medical in nature and not dental. You also say that you were 
advised that the treating provider cannot treat your tempomandibular joint (TMJ) problem. The Plan denied 
your request. The Plan says that the services you received are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There were no medical records provided in the case file, nor did the Plan request 
any.  
 
 
Since the services that you received are potentially covered services, medical records would be required to 
review for medical necessity. Additionally, the services were provided by a network provider with no evidence 
that you were informed that the services would not be covered. Therefore, we decided that the Plan has to pay 
for the office visit and x-ray provided on July 22, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (MyoPro Orthosis). 
 
You asked the Plan to pre-approve MyoPro device. You say that robotic rehabilitation, such as the MyoPro, has 
become a standard of care and this device is medically necessary. The Plan denied your request. The Plan says 
the denial of authorization for this item is correct, because this device is not known to be effective in improving 
short or long-term health outcomes. 
 
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 MyoPro device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found literature in peer-reviewed publications is not sufficient at this time to assess safety, long-term 
outcomes, and efficacy of the use of the MyoPro orthosis for upper extremity paralysis/paresis from spinal cord 
injury. Additional controlled studies with larger cohorts with long-term follow are needed to assess safety and 
efficacy of this device. At this time, this device is not proven to be at least as beneficial as an existing and 
available medically appropriate alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered upper extremity range of motion assist device (MyoPro Orthosis).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rhinoplasty. 
 
You asked the Plan to pre-approve these services. You say that the surgery is needed to restore ability to 
properly see with glasses. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that rhinoplasty 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 
the services are not medically necessary. Our physician reviewer found the enrollee has an acquired deformity 
of the nose. She underwent endonasal septoplasty on October 22, 2019, including caudal-septal reconstruction 
for acquired septal deviation. She was subsequently treated for a sinonasal infection and noted a lump growing 
over her nasal bones. The medical records do not contain photographic documentation, including frontal, lateral 
and worm's eye views, of the enrollee's condition. In addition, there is no documentation of a nasal deformity 
secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment, a 
chronic, non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves), or secondary to 
trauma, disease, or congenital defect, with nasal airway obstruction unresponsive to a recent trial of 
conservative medical management. The services are 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 rhinoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for periprosthetic capsulectomy, 
breast (19371) removal of mammary implant material (19330) provided June 4, 2020. 
 
You asked the Plan to pay for the assistant at surgery services. You say that the surgical assistant is an out of 
network provider who provided services in the best interest of the patient for which he nor the patient should be 
reduced payment or service benefits. The Plan denied your request. The Plan says Medicare guidelines state 
that an assistant surgeon may not be paid for this procedure. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for 
periprosthetic capsulectomy, breast (19371) removal of mammary implant material (19330) provided June 4, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for inpatient care provided on July 12, 2020. 
 
You asked the Plan to waive the cost share for inpatient care. The Plan denied your request. The Plan says the 
cost share applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract with the Plan says that the deductible is $1,250. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost for most of your covered services. Inpatient hospital care is not excluded from the 
deductible. The contract with the Plan says that you must pay a $300 copayment per admission after the 
deductible is met for each medically necessary inpatient stay at an in-network hospital. 
 
The item or service you asked the Plan to waive the cost share for falls within the "Inpatient hospital care" 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $1,250 
deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met 
at the time the inpatient care was received on July 12, 2020. Therefore, $1,160.35 has been applied to meet the 
deductible. 
  
Since the $1,250 has been met, a $300 copayment also applies. This means that you have been asked to pay the 
correct amount based on the 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 cost share 
for inpatient care provided on July 12, 2020.