Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that your doctor would like to perform 
a denture implant procedure however, he will not perform the oral surgery without hyperbaric treatments. 
Please reconsider approval as you are in constant pain. The Plan denied your request. The Plan says the records 
provided do not show a covered condition. Medicare does not cover dental implants as such any procedures 
done to facilitate or prepare for a non-covered service is not covered. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found review of the guidelines does not support the enrollee's diagnosis as a 
covered indication. Without the support of the documentation, medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental core buildup, and a mouth guard. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services 
are not covered. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental core 
buildup, and a mouth guard.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 21, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the documentation submitted 
does not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for evaluation and management of an 
established patient (99350) provided on April 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health visit. You say that authorization should not be needed under 
telemedicine for payment of services rendered. The Plan denied your request. The Plan says prior authorization 
must be used for non-emergent services rendered by an out-of-network provider. 
 
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 home visit for evaluation and management of 
an established patient (99350) provided on April 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on July 26, 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 Medicare billing criteria were not met. The Plan says that the echocardiography 
provided to the enrollee was denied as the maximum allowed amount dictated by Medicare billing 
requirements.  Based on CMS Chapter 15 (section 100.5.1 is for outpatient hospital) explains in detail how the 
provider should bill for reimbursement. Because the claim was not billed in accordance with CMS guidelines, 
no payment was made.  
 
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 has billing errors 
preventing payment. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to 
pay for outpatient services provided to the enrollee on July 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests provided on March 21, 2020. 
 
You asked the Plan to pay for laboratory tests. You say that the tests are medically necessary. You say that the 
claim should be reprocessed for full reimbursement. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 laboratory tests provided on March 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy implanted pain management infusion 
(S9328). 
 
You asked the Plan to pay for home infusion therapy implanted pain management. You say that the medical 
records submitted support the code used. The Plan denied your request. The Plan says the code used is not 
payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code S9328 is home infusion therapy implanted pain 
management infusion. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code is not valid for 
Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy implanted pain 
management have not been met. Therefore, we decided that the Plan does not have to pay for home infusion 
therapy implanted pain management infusion (S9328).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammography procedure 
(77065) performed on June 19, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammography procedure. You say that your 
review of your benefits indicated a lower copayment. 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). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests at all locations of service.  
 
You have been asked to pay a $75 copayment for a diagnostic mammography procedure. A diagnostic 
mammography procedure is distinct from a screening mammography. A diagnostic mammography procedure 
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 a diagnostic mammography procedure (77065) performed on June 
19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and a bone 
replacement graft (D4264). 
 
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that the 
Plan promised you a free implant. You also say that you were approved for the implant, but not for the surgery 
which you believe should be part of the approved procedure. The Plan denied your request. The Plan says these 
services are not covered under your benefit 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 pre-approve a 
guided tissue regeneration (D4266) and a bone replacement graft (D4264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trilogy home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a Trilogy home ventilator. You say that this is medically necessary. The 
Plan denied your request. The Plan says that there are other respiratory assist devices appropriate for this 
patient at this time. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Trilogy home ventilator. Our reviewer 
says that a Trilogy home ventilator is not medically reasonable and necessary for the enrollee in this case. The 
patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for a Trilogy home ventilator. 
 
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 Trilogy home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Trilogy home ventilator for the enrollee.
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 ongoing acute care needs can be met at the current acute care 
setting. 
 
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 patient 
appears to still require acute care services and has not yet gone through weaning attempts which could be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip replacement surgery to be provided by the requested 
physician. 
 
You asked the Plan to pre-approve the hip replacement surgery.  You say that this physician does the anterior 
procedure, which is much less invasive, the surgery is shorter and the recovery is much shorter and less painful. 
The Plan denied your request. The Plan says to receive coverage for services, you must receive services within 
the Plan's primary network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve hip 
replacement surgery to be provided by the requested physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported crown (D6066) and custom 
fabricated abutment (D6057). 
 
You asked the Plan to pre-approve the implant supported crown and custom fabricated abutment. The Plan 
denied your request. The Plan says these services are not covered by the enrollee's 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 pre-approve an 
implant supported crown (D6066) and custom fabricated abutment (D6057).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you were unaware you 
were limited to 20 visits per year. You say that it is necessary to receive physical therapy for your condition. 
The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for this condition 
and were trained in an independent exercise program. Our reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for evaluation and 
management of new patient (99327) provided on January 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit for evaluation and management of new patient. 
You say that the beneficiary was unable to leave the facility, forcing him to use the nurse on duty. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services provided by 
an out-of-network provider. 
 
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 domiciliary or rest home visit for evaluation 
and management of new patient (99327) provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Praluent pen. 
 
You asked the Plan to pre-approve Praluent. You say that the enrollee needs medication to control cholesterol. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 
Part B. 
 
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 a Praluent pen.  
 
Benefits for Praluent 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for an inpatient hospital stay 
provided by a non-participating provider on April 5, 2020, to April 27, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for an inpatient hospital stay. You say that you 
were told that copayments would be waived until the end of the year. The Plan denied your request. The Plan 
says the correct deductible and 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 $750 
deductible and a 40% coinsurance for inpatient hospital care/out-of-network.  
 
You have been asked to pay a $750 deductible and a 40% coinsurance for an inpatient hospital stay. The total 
amount you are being asked to pay is $8,555 which is less than your 40% coinsurance. Your maximum out of 
pocket amount has been reached. An inpatient hospital stay falls within the inpatient hospital care/out-of-
network 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 deductible and coinsurance for an 
inpatient hospital stay provided by a non-participating provider on April 5, 2020, to April 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 19, 
2018, to July 20, 2018. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
denial. 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 $295 
copayment per day for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from July 19, 2018, to July 20, 2018. Therefore, you are responsible to pay 
the $295 copayment.  
 
You have been asked to pay a $295 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the inpatient hospital care 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 
an inpatient hospital stay from July 19, 2018, to July 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided by a participating 
provider on December 19, 2018, to December 20, 2018. 
 
You asked the Plan to waive the coinsurance for injections. You say that this was sent to collections. You say 
that you did not know that you owed this because you have paperless bills. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total allowed amount 
is $554.69. The total amount you are being asked to pay is $110.95 ($554.69 x 20% = $110.95). The correct 
coinsurance has been applied to the services provided. Injections fall within the Medicare Part B prescription 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for injections provided by a 
participating provider on December 19, 2018, to December 20, 2018.