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

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751) and pontics (D6241). 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you have a missing bridge. 
You say that it broke on the right side and that you are having a hard time eating. You say that you have 
already lost 5 pounds in the last couple of weeks. The Plan denied your request. The Plan says the services 
which remain in dispute are not covered benefits under Medicare or your contract. 
 
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 
retainer crowns (D6751) and pontics (D6241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care 
 
You asked the Plan to pay for inpatient hospital care. You say that the entire say and level of care was 
appropriate as well as medically reasonable and necessary The Plan denied your request. The Plan says prior 
authorization must be obtained for services rendered by an out-of-network provider. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for inpatient hospital care. Our reviewer says 
that the post-stabilization care services were not medically necessary and reasonable. Our physician reviewer 
found the treating physician did not document that the patient was not stable for transfer on any dates of 
service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult undergarments for the enrollee. 
 
You asked the Plan to pre-approve the supplies. You say that the enrollee is not able to get to the bathroom on 
time. The Plan denied your request. The Plan says these are not used for comfort or convenience. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult undergarments for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital private room provided from December 
18, 2019, to December 27, 2019. 
 
You asked the Plan to pay for hospital private room. You say that you disagree with the Plan's denial of 
payment. The Plan denied your request. The Plan says the denial of payment for this private room is correct, 
because this private room was requested so you would not be disturbed by another patient and therefore the 
private room charge is not covered. 
 
The rules say that when a beneficiary requests private room accommodation, the hospital must inform the 
beneficiary of the additional charge. If the beneficiary accepts the liability, the hospital will supply the service, 
and bill the beneficiary directly. 
 
The private room for this stay was requested for your convenience. Therefore, the Plan does not cover this 
charge and the hospital bills you directly for this amount. Therefore, we decided that the Plan does not have to 
pay for an inpatient hospital private room provided from December 18, 2019, to December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a nonparticipating
provider on February 3, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you never had to pay for this before.
The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40%
coinsurance for Medicare Part B prescription drugs/in-network/other drugs.

You have been asked to pay a 40% coinsurance of the allowed amount for an injection. The allowed amount is
$2,332. The total amount you are being asked to pay is $466.40 ($2,332 x 20% = $466.40), which is less than
your coinsurance amount of 40%. The Plan has processed these services as in-network even though these
services were provided by an out-of-network provider. An injection falls within the Medicare Part B
prescription drugs/in-network/other 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 an injection provided by a non-participating provider on February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ultrasounds of extracranial arteries 
(93880) and intracranial arteries (93886) performed on February 19, 2020. 
 
You asked the Plan to waive the copayments for ultrasounds of extracranial and intracranial arteries. You say 
that the claim was processed incorrectly and that the copayment for diagnostic testing in office is supposed to 
be $30. The Plan denied your request. The Plan says the correct copayments were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a 
physician's office or at a free-standing facility.  
 
You have been asked to pay $310, or a $155 copayment for each of 2 ultrasounds. Ultrasounds of extracranial 
and intracranial arteries 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 copayments for ultrasounds of extracranial 
arteries (93880) and intracranial arteries (93886) performed on February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) abdomen (74183). 
 
You asked the Plan to pre-approve the MRI. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says the results of prior imaging that were the 
same or similar were provided, but did not show why the results are not sufficient for the evaluation of the 
current clinical condition. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the information provided by the CT scan on 9/15/20 is sufficient to make a clinical/surgical 
decision and an MRI would not assist with this decision process. 
 
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 magnetic resonance imaging (MRI) abdomen (74183).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is felt that intensive therapy is required to allow 
the enrollee to make gains. The Plan denied your request. The Plan says the IRF criteria are not met at this 
time. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for shortness of breath and a fall. He was treated for pneumonia and heart failure. Medical problems 
are stable. There are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT, professional component, provided on June 5, 2020. 
 
You asked the Plan to pay for the CT, professional component (70481). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the claim is missing the modifier used to indicate a distinct 
procedural service. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, the billing of code 70481 was submitted inappropriately due to the bundled relationship of services 
70450 within the specialty group. The modifier indicating the service as separate/distinct was not appended. 
Based on Medicare billing guidelines this claim cannot be paid as billed. Based on this information, we decided 
that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT, professional component, provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit 
(99214) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that you 
would like to continue care with this OON provider. The Plan denied your request. The Plan says there are 
multiple in-network providers able to provide the requested service. 
 
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 
the established patient office or other outpatient visit (99214) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
March 9, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that you would like this claim 
reprocessed and approved for payment. 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 subsequent nursing facility visit (99309) 
provided on March 9, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99213) on March 17, 
2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the enrollee's diagnosis 
indicates the service at issue was related to COVID-19. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $30 copayment for each visit in a contracted Urgent Care Center or walk-in clinic.  
 
The enrollee has been asked to pay a $30 copayment for an urgent care visit. An urgent care visit falls within 
the "Urgently Needed Services" benefit category. The case record documents that the Plan's waiver of 
copayments related to the COVID-19 pandemic does not apply to emergency, urgent, and ambulance services. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an urgent care visit (99213) on March 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Palonosetron. Our reviewer says that 
Palonosetron is not medically reasonable and necessary in this case. Our physician reviewer found that the use 
of Palonosetron is indicated and recommended as part of combination anti-emetic therapy for moderate or 
highly emetic risk chemotherapy. Per the NCCN Guidelines Version 2.2020 Antiemesis page AE-3, Taxol 
(Paclitaxel) has low emetic risk and Herceptin (Trastuzumab) has minimal emetic risk. Therefore, the 
documentation does not support that Palonosetron is medically reasonable and necessary to treat the enrollee. 
The documentation does not support that the drug is safe and effective for the 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 Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you brought your medications to the 
hospital with you, and were told to have your husband take them home. The Plan denied your request. The Plan 
says benefits for this service are excluded under your plan. 
 
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 pay for the self-administered drugs 
provided on July 10, 2020.  
 
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on February 26, 
2020. 
 
You asked the Plan to pay for the lower partial denture (D5214). You say that the bridge could not be repaired 
so a partial denture is required. You say that the procedure started in 2019 but the plan changed in 2020 
negating coverage. 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 lower 
partial denture (D5214) provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap for a wheelchair. 
 
You asked the Plan to pre-approve the privacy flap. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a privacy flap for a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aflibercept. 
 
You asked the Plan to pre-approve Aflibercept. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aflibercept. Our reviewer says that 
Aflibercept is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that the documentation provided does not include exam notes for the enrollee, although clinical 
information has been included in the letters. The notes indicate that the enrollee has received both 
Bevacizumab and Aflibercept injections for subretinal fluid and that both treatments are effective. It does not 
specifically state that Aflibercept is more effective or better tolerated by the enrollee, and therefore it remains 
unclear if it is medically necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aflibercept have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aflibercept.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on July 2, 
2020. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you were not informed of the 
charges ahead of time. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $350 copayment for a cystourethroscopy. A cystourethroscopy 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 copayment for a cystourethroscopy provided on 
July 2, 2020.