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

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical 
x-ray (D0230), and the root canal (D3330) provided on May 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would have had to have that tooth extracted 
if you did not receive the root canal on the date of service. You say that having this tooth removed would 
severely limit your ability to eat and lead to poor health. You also say that you are on a fixed income and this is 
a significant bill. The Plan denied your request. The Plan says periapical x-rays are not listed as a covered 
service. The Plan also says root canals are not listed as a covered service either. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), 
the additional periapical x-ray (D0230), and the root canal (D3330) provided on May 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy (29881). 
 
You asked the Plan to pre-approve knee arthroscopy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence based medical literature does not support arthroscopic 
meniscectomy at this time. There is no clear evidence of positive meniscal provocative testing or mechanical 
symptoms to support proceeding with surgery in the setting of tricompartmental osteoarthritis, severe in the 
medial compartment. Additionally, there is no evidence of exhausted conservative treatment, including 
physical therapy or hyaluronic acid injections. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request at this time. Therefore, this request for left 
knee arthroscopy with meniscectomy is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy (29881).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyramza for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says before this drug can be covered, it must be used for a medically accepted indication. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Cyramza is FDA 
approved for the treatment (as a single agent) of hepatocellular carcinoma in patients who have an alpha 
fetoprotein of =400 ng/mL and have been treated with Sorafenib. Although the AFP is over 400 the enrollee 
has not received Sorafenib. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cyramza for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $80 copayment charged for emergency room services 
provided on April 30, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $80 
copayment for emergency room services.  
 
You have been asked to pay $80 copayment for this copayment. this copayment falls within the emergency 
room services 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 $80 copayment charged for emergency 
room services provided on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the rebase of a complete maxillary denture (D5710).

You asked the Plan to pre-approve the dental service. You say that the acrylic base of the enrollee's current dentures burns his palate. You say that the enrollee's denture will need a complete rebase rather than a reline in order to completely remove the allergen. You say that you are aware of the 6 month time period before insurance will cover this service but are requesting an exception due to the enrollee's allergy and inability to wear the appliance at all. The Plan denied your request. The Plan says a denture rebase is not listed as a covered service. The Plan also says any services not listed 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the rebase of a complete maxillary denture (D5710).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the patient office consultation (99243) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the patient office consultation. You say that you believe that you might need 
more stents. The Plan denied your request. The Plan says cardiology specialty services are available within 
your 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 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 patient office consultation (99243) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this should be covered. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered by 
Medicare when the beneficiary has been using a blood glucose monitor and testing four or more times a day 
and is insulin-treated with three or more daily injections of insulin. 
  
 
We looked at the file and Medicare rules. The records do not show that the enrollee is testing four or more 
times a day and is insulin-treated with three or more daily injections of insulin. Based on this information, we 
decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy services you received 
from an out-of-network provider on February 12, 2019. 
 
You asked the Plan to waive the copayments for the physical therapy services. You say that you were traveling 
and activated your Passport program, so you should only be charged the in-network cost sharing. The Plan 
denied your request. The Plan says although you did activate the Passport program, you did not use an 
Affiliated network provider.  The provider you used is an out-of-network provider, so you were 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 $70 
copayment for physical therapy services received out-of-network.  
 
You have been asked to pay a $70 copayment for the physical therapy services with an out-of-network 
provider. 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 physical therapy services you received from 
an out-of-network provider on February 12, 2019.  Please note that this decision is limited to the February 12, 
2019 date of service.  If you wish to appeal other dates of service, please contact your plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tdap vaccine received on June 24, 2020. 
 
You asked the Plan to pay for the vaccine. You say that you live on a farm, and feel that it is important to keep 
this up to date. The Plan denied your request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tdap vaccine received on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lumbar epidural steroid injection provided 
on June 3, 2020. 
 
You asked the Plan to waive the copayment for the injection. You say that you feel this should be billed as part 
of the specialist visit. You should have a $40 copay because the injections are done during the office visit. The 
Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the 
plan benefits. 
 
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 $250 per 
day for outpatient procedures and services, including, but not limited to outpatient surgery performed in an 
outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay $250 for the injection. The injection falls within the Outpatient hospital services 
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 lumbar epidural steroid injection 
provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic shoes and inserts (A5513NU and 
A5500NU). 
 
You asked the Plan to pre-approve foot orthotics. You say that you have been denied because you are not a 
diabetic, however you have neuropathy in your feet. You are in need of special shoes and orthotics to take the 
pressure off the soar when you walk. The Plan denied your request. The Plan says this enrollee does not meet 
the Medicare criteria for the requested orthopedic shoes and custom shoe insert. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the therapeutic shoes and inserts 
(A5513NU and A5500NU).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on October 11, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for breast cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360? molecular pathology genomic profiling provided to the enrollee on October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services (71045, Q0092, R0070) provided 
on March 31, 2020. 
 
You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the mobile x-ray services (71045, Q0092, R0070) provided on March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prophylaxis (D1110). 
 
You asked the Plan to pre-approve the prophylaxis (D1110). You say that the enrollee has Sjogren?s disease as 
well as connective tissue disease and would be benefit from a dental cleaning 3-4 times per year for optimal 
health. The Plan denied your request. The Plan says the service exceeds the maximum count allowed per 
period. 
 
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 Plan also has a maximum benefit 
of two cleanings per plan year. The enrollee had a cleaning on May 27, 2020 and January 24, 2020, which 
exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the prophylaxis 
(D1110).
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF 
care. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar surgery. He was discharged to skilled nursing and now has been discharged to home. 
Medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, 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 the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D testing provided on February 6, 2020. 
 
You asked the Plan to pay for the vitamin D testing. You say that the testing was medically necessary and 
should be covered. The Plan denied your request. The Plan says this testing was performed for screening 
purposes and cannot be covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. More specifically, vitamin testing may only be covered when there is a 
clinical presentation or comorbid condition for which this testing may be indicated. 
 
In this case, the vitamin D testing was billed with diagnosis code Z00.00, meaning that there were no abnormal 
findings during a preventive exam. This testing is not covered for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the vitamin D testing provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-treatment of a root canal (D3346) and crown repair 
(D2980) provided on May 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had an infection all over your mouth. You 
say that you were advised you needed a root canal redone. You say that it is not fair that you should have to 
pay for the root canal again. The Plan denied your request. The Plan says re-treatment of a root canal is not 
listed as a covered service. The Plan says crown repair is not listed as a covered service. The Plan also says any 
services not listed 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
re-treatment of a root canal (D3346) and crown repair (D2980) provided on May 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical and occupational therapies provided on March 
2, 2020 to March 31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical and occupational therapies. You say that services rendered were 
medically necessary. The Plan denied your request. The Plan says members must use in-network providers 
unless prior authorization was obtained. 
 
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 physical and occupational therapies provided 
on March 2, 2020 to March 31, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1851, L2397, L2385) provided April 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The provided delivery ticket is not itemized and the 
delivery date does not match the dates of service on the claim submitted. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for orthoses (L1851, L2397, L2385) provided April 15, 2020.