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

 
We decided that the Plan does not have to pay for the surgical placement of an implant body: endosteal implant 
for tooth #13 provided on June 23, 2020. 
 
You asked the Plan to pay for the endosteal implant. You say that you feel this service should be covered 
because it was supposed to be done under your prior insurance plan. You also say that you had to change 
insurance plans due to turning 65. The Plan denied your request. The Plan says tooth #13 is a posterior (back) 
tooth. The Plan also says that tooth #13 was extracted in December of 2019, prior to your coverage with the 
Plan becoming effective. 
 
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 
surgical placement of an implant body: endosteal implant for tooth #13 provided on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no required medical 
services identified that are available at the LTACH, that are not available at the current health care setting 
being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 17, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the labs were for your annual 
wellness visit and you have never been charged a copayment in the past. 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 $0 
copayment for lab services provided by a primary care physician, specialist or in a freestanding laboratory and 
a $35 copayment for lab services provided in an outpatient hospital facility.  
 
The record shows that you received laboratory services at an outpatient hospital facility on June 17, 2020. 
Therefore, you are responsible to pay the allowed amount of $13.56, which is less than the $35 copayment.  
 
You have been asked to pay $13.56 for laboratory services. Laboratory services 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 
copayment for laboratory services provided on June 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered from December 28, 
2019 to December 29, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 
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 the outpatient hospital services rendered from December 28, 
2019 to December 29, 2019.
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 the enrollee meets the criteria for coverage of IRF 
care. The Plan denied your request. The Plan says the records show the enrollee does not need evaluations by 
rehab doctors, nor does she need to take part in 3 hours of therapy daily for 5 days a week. The Plan says that 
the enrollee can safely receive the services needed in another setting. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided 
on June 26, 2020 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you are covered 
for both in-network and out-of-network dental services. You also say that you believe you are entitled to a 
reimbursement for the difference. The Plan denied your request. The Plan says the cost share was applied 
correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the plan and 
cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more 
for the periodic oral evaluation and prophylaxis provided on June 26, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee.  You say that this claim should be paid. The 
Plan denied your request. The Plan says the documentation submitted did not support that the denied codes 
were performed with blood sampling.  The Plan says that blood specimen collection is by venipuncture; 
however, the lab requisition states a urine specimen was collected. Therefore, the billed service cannot be 
verified. It is noted multiple attempts were made to obtain additional information from the provider. 
 
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 cannot be paid due 
to an issue with the reported specimen used. Medicare billing criteria are not met. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on June 4, 2020 and billed under codes  
80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a mandibular partial denture.You asked the Plan to pre-approvethe complete maxillary denture and mandibular partial denture. You say that you have never had these services done.The Plan denied your request. The Plan says these services are not covered by yourplan.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-approvea complete maxillary denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe office visit (99203 and 99213) to be provided byan out of network (OON) provider.You asked the Plan to pre-approveoffice visit. You say that you do not agree with the Plan's denial.The Plan denied your request. The Plan says your plan does not cover services with a doctor outside the Plan'snetwork unless your Plan does not have a doctor who can treat your condition. Your Plan's network has specialty providers who are able to treat your condition.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-approvethe office visit (99203 and 99213) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe GeneSight Psychotropic test provided to the enrollee on September 24, 2019.You asked the Planto pay forthe test. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation does not support a failure of any neuropsychiatric medication treatment.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 pay for the test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the information provided, this enrollee has not responded to at least one other medication which is noted in the record as well as being on multiple medications for her condition which increase the risk of adverse effects however she only took the medications for 2 weeks which is not considered an adequate trial. Utilizing the information from Medicare LCD L35443 it does appear that the GeneSight Psychotropic Assay is considered medically necessary and reasonable in the treatment of this 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 the test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe GeneSight Psychotropic test provided to the enrollee on September 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One right knee injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records did not show a trial and failure simple pain medication like 
ibuprofen or acetaminophen. 
 
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 the injections. Our reviewer says that 
the requested injections is not medically reasonable or necessary. Our physician reviewer found a diagnosis of 
osteoarthritis of the right knee has not been documented or supported by radiologic evidence. In addition, other 
diagnoses have not been excluded by appropriate evaluation and management services. There is no 
documentation indicating the enrollee has failed conservative therapy (such as Acetominophen or NSAIDs). 
The service at issue in this case is not medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One right knee injections for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from November 15, 2019 to November 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from November 15, 2019 to November 18, 2019.
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 the enrollee continues to 
have decreased range of motion, strength, mobility and function. You say that therapy is necessary to improve 
function and decrease her risk of falling. 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 the enrollee has had extensive therapy for this 
condition and is competent in a home 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not ready to go home. The Plan denied 
your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that continued care is the only 
option to improve 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 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 additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care received on May 19, 
2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should be paying $225 
due to erroneous information received from a representative of the Plan. 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 $325 
copayment for each day of days 1-5 of each Medicare-covered hospital admission/stay.  
 
You have been asked to pay a $325 copayment for 1 day of inpatient hospital care. Inpatient hospital care 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 
inpatient hospital care received on May 19, 2020.  
 
Your complaint about receiving erroneous or ambiguous information regarding your cost-sharing 
responsibilities from a representative of the Plan 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the pelvis. 
 
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. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee is indicated for surgery and the 
surgeon requested the CT scan of the pelvis prior to surgery. The CT scan is reasonable and medically 
necessary for the enrollee for this indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the pelvis.  
 
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.