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

 
We decided that the Plan does not have to pay for the cone beam CT capture (D0364) provided on May 19, 
2020. 
 
You asked the Plan to pay for the cone beam CT capture. You say that the CT of the tooth was done to 
determine if there was a problem with the root nerve. You say that a root canal would have been performed if 
the CT capture wasn't performed. The Plan denied your request. The Plan says 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. 
 
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 cone 
beam CT capture (D0364) provided on May 19, 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 June 24, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the visit was a week before 
copayments were waived due to COVID-19 and you request that your copayment also be waived. 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 doctors 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 June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you the copayment for the inpatient services provided 
from March 31, 2020, to April 14, 2020. 
 
You asked the Plan to reimburse you the copayment for the inpatient services. You say that the second 
admission should be a continuation of the first admission and therefore the copayment should be less. The Plan 
denied your request. The Plan says you were not readmitted within 24 hours therefore you have been charged 
this copayment 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 $200 
copayment per day for days 1-7 for Inpatient Hospital Care.  
 
You have been asked to pay a $200 copayment per day for days 1-7 for the inpatient services. The inpatient 
services fall within the Inpatient Hospital Care benefit category. The record shows you were not readmitted 
within 24 hours. 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 reimburse you the copayment for the inpatient services 
provided from March 31, 2020, to April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure (22899). You say that the Intracept procedure is 
necessary for the enrollee's disabling pain. The Plan denied your request. The Plan says the Intracept Procedure 
(22899) is considered experimental and investigational. 
 
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 an Intracept procedure (22899). Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure (22899) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic and retainer crown for a bridge. 
 
You asked the Plan to pre-approve the pontic and retainer crown. You say that the tooth underneath the bridge 
is decaying. You say that in order to fix the decay the bridge needs to be replaced. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
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 
pontic and retainer crown for a bridge.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee would be able to take part in 3 hours of therapy a day.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 physician reviewer found that you were admitted to the acute hospital for COVID-19 associated pneumonia, complicated by acute respiratory distress syndrome, atrial fibrillation and NSTEMI. Your medical problems are stable. The complexity of yournursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You donot require treatment by multiple therapies, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy,but it does not support a need for an intensive rehabilitation therapy program.There is not a reasonable expectation that youwill be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore,the requested services are 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup. 
 
You asked the Plan to pre-approve core buildup. You say that you have more sensitivity in your denture. You 
say that you can only have the 3 services done that were approved. The Plan denied your request. The Plan says 
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. 
 
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 core 
buildup.  
 
Your complaint about the Plan being abusive and irresponsible is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued SNF stay. 
 
You asked the Plan to pre-approve the continued SNF services. You say that you still require additional care. 
You also say that it is not safe for you to be discharged home right now. The Plan denied your request. The 
Plan says the documentation does not show that the care you require needs to be delivered in a SNF. 
 
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 continued SNF services. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF setting. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continued SNF stay.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) office visits from October 9, 2020, through 
October 9, 2020, with an out-of-network provider. 
 
You asked the Plan to pre-approve the office visits. You say that the services are necessary. The Plan denied 
your request. The Plan says this provider is out of network and does not work within the member's plan. The 
Plan states they modified the request to allow a partial number of visits to give the member time to find another 
provider. The Plan states medical director approved 6 visits instead of 12 and the medical director approved a 
period for these visits for only 90 days from October 01, 2020, to January 01, 2021. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
twelve (12) office visits from October 9, 2020, through October 9, 2020, with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 83970, 85027, 80069, 84156, 
82570) provided on July 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 the laboratory services (36415, 83970, 85027, 
80069, 84156, 82570) provided on July 16, 2020, by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 5, 2020. 
 
You asked the Plan to pay for office visit. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee 
was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment 
of this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair.You asked the Plan to pre-approvea power wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested power wheelchair is 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 a power wheelchair. Our reviewer says that the documentation does not support that the requested power wheelchair is medically reasonable or necessary. Our physician reviewer found the documentation does not support that you have a personal mobility deficit thatimpairs participation in mobility related activities of daily living in the home. The documentation does not reveal why you are unable to be helped by a walker, cane, or manual wheelchair. You were noted in a progress note to have normal gait, motor, sensory testing. Therefore, you do not meet criteria for the requested item. 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 power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reimbursement for meals provided through a wellness 
program. 
 
You asked the Plan to pay for the meals. You say that the meals should be covered. The Plan denied your 
request. The Plan says the meals are not a covered benefit. 
 
The rules say that Medicare does not cover gym or fitness benefits. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym 
benefits only up to $240 per year for a membership in health club/fitness classes, health education, nutritional 
benefits, and/or Weight management program. 
 
The Plan?s rules for coverage of fitness benefits have not been met because there is no coverage for meals or 
supplements. Therefore, we decided that the Plan does not have to pay for reimbursement for meals provided 
through a wellness program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup on tooth #18 (D2950). 
 
You asked the Plan to pre-approve core buildup on tooth #18. You say that the service is necessary. The Plan 
denied your request. The Plan says 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. 
 
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 core 
buildup on tooth #18 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the item is necessary. The Plan denied your request. 
The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has not been 
met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says the benefit for crowns has been exhausted. 
 
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 benefit for crowns has been 
exhausted. The plan covers one crown every 60 months. A crown was previously provided on August 15, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that Keytruda as a 
single agent does not meet coverage criteria. 
 
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 did not provide medical record documentation to support their decision to deny the requested drug. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Therefore, we decided that the Plan has to pre-approve pembrolizumab 
(Keytruda).  
 
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.