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

 
We decided that the Plan does not have to pay for the surgical implant placements (D6010) and osseous, 
osteoperiosteal, or cartilage graft (D7950) provided on July 29, 2020. 
 
You asked the Plan to pay for the surgical implant placements (D6010), osseous and osteoperiosteal, or 
cartilage graft (D7950). You say that the doctor was not able to properly monitor the graft done in 2019 so it 
failed. You say that these services are medically necessary, not a cosmetic procedure. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 
 
 
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical implant placements (D6010) and osseous, osteoperiosteal, or cartilage graft (D7950) provided on July 
29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the 
out of network (OON) provider on September 8, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider on 
September 8, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the EGD provided on May 26, 2020. 
 
You asked the Plan to reduce the copayment for the EGD. You say that you have never paid this much for the 
same service. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $300 
copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital 
facility or ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for the EGD. The EGD 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 reduce the copayment for the EGD provided on May 26, 2020. 
  
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact 
the plan directly.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on April 18, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you waited a long time 
to be seen. You say that you shouldn't have to pay because of this. The Plan denied your request. The Plan says 
the correct copayment 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 emergency room visit 
provided by a participating provider on April 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services (96136, 96130, 96131) 
provided on August 3, 2020 to August 16, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
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 outpatient mental health services (96136, 96130, 96131) provided on August 
3, 2020 to August 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build up (D2950) and prefabricated stainless steel 
crown - permanent tooth (D2931). 
 
You asked the Plan to pre-approve a core build up and crown. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Specifically, the services are not listed in the Plan?s dental customer 
handbook. This means the services are not covered benefits. Therefore, we decided that the Plan does not have 
to pre-approve a core build up (D2950) and prefabricated stainless steel crown - permanent tooth (D2931).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
July 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 4, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 2, 2019. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for the physician services was not filed until September 1, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on July 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-rays (D0210) and the comprehensive 
oral evaluation (D0150) provided. 
 
You asked the Plan to pay for the dental services. You say that you had a toothache. You say that the x-ray was 
necessary to determine what was causing your pain. You also say that the bill of $195 is a lot of money for you 
as you are on a limited income. The Plan denied your request. The Plan says 1 full mouth or panoramic x-ray is 
covered every 5 years. The Plan says that 1 periodontal or comprehensive oral evaluation is covered every 3 
years. The Plan also says that the frequency limits for these services have been exceeded. 
 
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 frequency limit of 1 full mouth x-
ray every 5 years has been exceeded. The record shows that the Plan paid for this service that you received,
less than 5 years ago. Additionally, the frequency limit of 1 comprehensive oral evaluation 
every 3 years has been exceeded. The record shows that the Plan paid for this service that you received, 
less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the 
complete series of x-rays (D0210) and the comprehensive oral evaluation (D0150) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery and fusion. 
 
You asked the Plan to pre-approve the spinal surgery and fusion. You say that the medical records provided 
support the need for the requested surgery. The Plan denied your request. The Plan says the requested 
procedure has not been shown to be helpful for the enrollee's condition. The Plan says that the requested 
service is not medically necessary. 
 
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 the spinal surgery and fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found surgery using the Vertiflex device is not medically needed. The device is 
experimental, and more research is needed to show safety and efficacy. Our physician reviewer found that there 
is no spinal instability and that hardware is not needed. 
 
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 spinal surgery and fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal surgery and fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that this doctor did your knee surgery 
before. You say that you would like to see this doctor again. The Plan denied your request. The Plan says there 
are in-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 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 
a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (V2781, V2025, V2750) provided June 30, 
2020. 
 
You asked the Plan to pay for the vision services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says vision services received out-of-network are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only when obtained from contracted providers. 
 
We looked at the file and the Plan's rules. The services were received out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for vision services (V2781, V2025, V2750) provided June 30, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of home health visits for skilled nursing 
services. 
 
You asked the Plan to pre-approve home health visits. You say that you were denied home health. You say that 
you went to see the PM and the reason why you have been in so much pain is because you have developed 
arthritis in your pelvis. You say that you are not able to walk. You also say that you need the nurse to continue 
coming to your home. The Plan denied your request. The Plan says you do not have a medical problem that 
needs special care that only a skilled person can do. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health visits. Our reviewer says 
that the continuation of skilled nursing services is not medically necessary. Our physician reviewer found the 
provided documentation does not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that 
no unstable acute or chronic medical conditions are documented in the records to necessitate additional skilled 
nursing 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 home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuation of home health visits for skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient 
rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that you do not require the intensity of services provided at an inpatient rehabilitation 
facility. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services 
with regular physician evaluation. Your 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block and radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular nerve block and radiofrequency ablation. You say that the 
records provided support the medical necessity of the requested services. The Plan denied your request. The 
Plan says the requested procedures are investigational and experimental. 
 
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 the genicular nerve block and 
radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a medical history that 
includes chronic low back pain, sciatica, and chronic bilateral knee pain. Our physician reviewer says that 
genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary 
for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint 
disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee 
replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 
 
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 genicular nerve block and radiofrequency ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block and radiofrequency 
ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blepharoplasty (15823) provided on March 19, 2020 
 
You asked the Plan to pay for blepharoplasty. You say that this was medically necessary. The Plan denied your 
request. The Plan says there are not photographs to support this was necessary. 
 
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 blepharoplasty. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found he documentation is insufficient to demonstrate that bilateral upper eyelid blepharoplasty was medically 
reasonable and necessary for the enrollee in this case. The clinical documentation and photographs are 
inadequate to support that this enrollee had functional visual impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pay for blepharoplasty (15823) provided on March 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal with an oral surgeon. 
 
You asked the Plan to pre-approve these services. You say that you are in extreme pain. The Plan denied your 
request. The Plan says services from an oral surgeon 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 Plans coverage rules apply in this case. The Plan covers supplemental 
dental benefits from a participating general dentist only. 
 
We looked at the file and the Plan?s rules. The requested services are a root canal from an oral surgeon. Based 
on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a root canal with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retainer crowns and pontic for a fixed bridge. 
 
You asked the Plan to pre-approve the retainer crowns and pontic. You say that the least costly and best option 
for your health is a fixed bridge. You say that the dentist also advised this was the best option. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
retainer crowns and pontic for a fixed bridge.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided from April 29, 2020, to June 10, 2020. 
 
You asked the Plan to pay for the physician services. You say that you are not on the LEIE from OIG for 
Medicare exclusion. The Plan denied your request. The Plan says you are excluded or debarred from 
participation in State and Federal health care programs. 
 
The Plan must follow Medicare rules. Medicare rules say that if someone is on the LEIE they are not allowed 
to receive reimbursement for providing Medicare and Medicaid services in any capacity even if they are on this 
listing.  
 
We looked at the file and Medicare rules. This provider is not federally sanctioned. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided from April 29, 2020, to June 10, 2020.