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

We decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework 
with resin denture bases (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you were provided with 
misinformation and would like this claim per-approved for coverage. The Plan denied your request. The Plan 
says these services are not covered under the member's benefit package. 
 
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 the 
maxillary partial denture - cast metal framework with resin denture bases (D5213).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee January 7, 
2020 to January 29, 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 per the Medicare guidelines the provider did not bill with the claim an appropriate ?Q? 
code on the claim. The Plan states a corrected claim would be reviewed if submitted.  
 
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 submitted is lacking the 
required ?Q? code. Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for home health services provided to the enrollee January 7, 2020 to January 29, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on June 2, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that this was a routine EKG during a 
wellness exam. You say that this should be fully covered. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay $16.47, which is less than the standard $20 copayment for the EKG. The EKG 
falls 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 the EKG provided on June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary. 
 The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested PET scan. 
 
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 a PET scan. Our reviewer says that the 
enrollee does not meet criteria for the requested PET scan. Our physician reviewer found the medical records 
provided for review did not support that the member meets diagnostic criteria for both AD and FTD. Nor is it 
clear from the records that other "alternate neurodegenerative diseases or other causative factors, but the cause 
of the clinical symptoms remains uncertain." The notes for review simply suggested the presence of a 
progressive MCI. As the records did not support findings consistent with diagnostic criteria for both AD and 
FTD, the proposed service would not be 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral first radiographic X-ray (D0220) provided on 
August 5, 2020. 
 
You asked the Plan to pay for the intraoral first radiographic X-ray. You say that you would like the claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this service is never 
covered under your supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
intraoral first radiographic X-ray (D0220) provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 5, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services provided to the enrollee on June 25, 2020. 
 
You asked the Plan to pay for this service. You say that these services were provided to the enrollee and should 
be covered by the Plan. You also stated that you were told this claim was denied for timeliness. The Plan 
denied your request. The Plan says that ?the service you requested has been reviewed and the documentation 
provided by your physician does not support the need for this service of Office Visit Level 5 and therefore, 
your request is denied. This decision is based on clinical records available do not justify level of request.? 
 
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 case file submitted by the Plan contained 10 pages with no clear explanation of the Plans denial.  
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  The case file submitted does not substantiate the Plans denial. Therefore, we 
decided that the Plan has to pay for physician services provided to the enrollee on June 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit provided on August 3, 
2020. 
 
You asked the Plan to waive the copayments for a specialist visit. You say that you changed your primary care 
provider and disagree with the specialist charges. 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 $50 
copayment for each specialist visit. 
 
The record shows that you received specialist services on August 3, 2020. Therefore, you are responsible to 
pay the $50 copayment.   
 
You have been asked to pay a $50 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 copayments for a specialist visit provided on August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this procedure 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that adjacent segment fusion surgery is not needed at this time. There is no documentation of 
adequate conservative measures to include physical therapy for neck pain. There are no red flags for surgery. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the durable medical equipment provided. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you met your deductible in 
March. The Plan denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay after 
your yearly deductible is met, you pay 20% for Medicare-covered equipment and supplies for durable medical 
equipment.  
 
The file shows that, at the time the claim was processed, you had not met your $300 deductible. You have been 
asked to pay $287.01, which allowed you to reach your deductible amount. You were then charged $2.21, 
which is 20% of the remaining balance. The services fall within the durable medical equipment 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 cost shares for the durable medical equipment provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with COVID-19 
pneumonia and related delirium and fever. The enrollee was treated with oxygen, convalescent plasma, and 
antibiotics. The course was complicated with fluid overload causing the enrollee to require more oxygen 
supplementation, but the enrollee is refusing hemodialysis. The enrollee appears to be having a set back and 
only requires short term additional acute care hospital services which can be completed at the current facility. 
The enrollee does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. 
 
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Aranesp. 
 
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 that the services are not medically necessary. 
 
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. The Plan states that Aranesp is not medically necessary; however, the Plan has 
not provided any medical records. Without medical records, a determination based on medical necessity cannot 
be supported. Therefore, we decided that the Plan has to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
August 31, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided do not meet criteria 
for coverage under the member's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and the Plan?s rules. Based on this information, we decided that the Plan?s rules for 
coverage of the acupuncture services have not been met.  
 
 
 
Specifically, the acupuncture was not provided by a physician licensed to perform the service. This means that 
the acupuncture services are not eligible for coverage by the Plan. Additionally, these services were not 
provided for treatment of chronic lower back pain and are therefore, also not eligible for coverage by Medicare. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) 
provided on August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says in the absence of a osteoporotic fracture, a trial of Zoledronic Acid is required before 
Prolia can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the documentation does not support a history of an 
osteoporotic fracture or previous treatment, contraindication, or intolerance to Zoledronic acid. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on June 9, 2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with documents to support 
coverage. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
these tests are not a Medicare benefit for the diagnoses listed and were performed for screening purposes.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic 
screening testing provided on June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the physician told you that you would have to leave 
the hospital soon however, you cannot receive the proper care at home. The Plan denied your request. The Plan 
says based on Medicare guidelines, the IRF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the health Plan's denial should be 
upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to 
require, or to be able to perform, fifteen hours per week of rehabilitative services and regular physician 
evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 16, 2020. 
 
You asked the Plan to pay for the dental service. You say that you did not authorize the full mouth x-ray 
because you had your 2 x-rays on file. You also say that you did not ask for the x-ray. The Plan denied your 
request. The Plan says 1 full mouth x-ray is covered every 5 years. The Plan also says that the frequency limit 
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 frequency limit of 1 full mouth x-
ray every 5 years has been exceeded. The record shows that the Plan paid for a full mouth x-ray that you 
received on February 7, 2019, thus exhausting the benefit. Therefore, we decided that the Plan does not have to 
pay for the panoramic x-ray (D0330) provided on July 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for neuroplasty provided on November 13, 
2019, and December 11, 2019. 
 
You asked the Plan to waive the copayments for neuroplasty. You say that you were told that you would not 
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 $300 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You received neuroplasty on November 13, 2019. Neuroplasty is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the $300 copayment.  
 
You received neuroplasty on December 11, 2019. Neuroplasty is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the $300 copayment. 
 
The total amount you owe is: $600.  
 
You have been asked to pay the total copayment amount of $600 for neuroplasty. Neuroplasty falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 copayments for neuroplasty provided on 
November 13, 2019, and December 11, 2019.