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

We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and bitewing 
x-rays provided on June 9, 2020.  
 
You asked the Plan to pay for the prophylaxis, comprehensive oral evaluation and bitewing x-rays. You say 
that there is a $0 copayment for an annual routine visit. You say that you will receive what you are entitled to. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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 is only obligated to pay the 
allowed amount for your covered dental services from an out-of-network provider. You are responsible for any 
amount greater than the payment made by the Plan. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis, comprehensive oral evaluation and bitewing x-rays provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for debridement provided from April 16, 
2020, to May 11, 2020. 
 
You asked the Plan to waive the copayments for debridement. You say that you disagree with how the claims 
were billed and you were not charged this much 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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received debridement from April 16, 2020, to May 11, 2020 for a total of 4 services. Wound debridement 
is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 copayment per 
each service. The total amount you owe is: $225 (copayment) x 4 (debridement services) = $900.  
 
You have been asked to pay the total copayment amount of $900 for debridement. Debridement falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for debridement provided from 
April 16, 2020, to May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple power options for a wheelchair (E2311, E2377, 
E2313, E2300). 
 
You asked the Plan to pre-approve the power options. You say that the enrollee is not able to walk. The Plan 
denied your request. The Plan says this 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 power options. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the enrollee meets the criteria for the multiple power options for 
the power wheelchair. There are no medical conditions that would indicate these options. 
 
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 power options have not been met. Therefore, we decided that the Plan does 
not have to pre-approve multiple power options for a wheelchair (E2311, E2377, E2313, E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  bone replacement  graft  for  ridge  preservation,  maxillary interim  partial  denture,  and two external  bleachings  for  home  application  on June  19, 2019.You asked the  Plan to pay  forthe  bone replacement  graft,  maxillary  interim  partial  denture,  and external bleachings.  You  say that the  approved amount  for these  services  was $808.80. You also  say that  you  should have  been reimbursed  more  than  $243.20.The  Plan  denied  your  request. The Plan  says these  services  are not covered  under  your  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 pay forthe bone replacement  graft  for  ridge  preservation,  maxillary  interim  partial  denture,  and two external  bleachings  for home  application  on June  19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided November 10, 2019. 
 
You asked the Plan to pay for physician services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says all care provided during the inpatient stay in which the surgery occurred is 
compensated through the global surgical payment, unless it is an unrelated service notated with a proper 
modifier. 
 
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 CPT code 99232 is not supported in the medical record. Specifically, while the evaluation and 
management service was unrelated to the global procedure, a modifier to denote a separately payable, unrelated 
service was not included. Based on this information, we decided that Medicare rules for coverage of physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99232) provided November 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 60 allotted one-way 
transportation trips for the 2020 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin test for tuberculosis (86580) provided on September 
4, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the skin test for tuberculosis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the skin test for tuberculosis (86580) provided on 
September 4, 2019, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for drug test. You say that you are appealing with medical records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-
network with the Plan and the ordering physician is also out-of-network with the Plan. 
 
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 medical services provided on February 5, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a bone replacement 
graft (D4263). 
 
You asked the Plan to pre-approve the dental services. You say that you understand that implants are not a 
covered service. You say that you need it and it is not cosmetic. You say that you cannot chew well. You also 
say that you cannot afford to pay for this by yourself. The Plan denied your request. The Plan says endosteal 
implant is not listed as a covered service. The Plan says bone replacement graft is not listed as a covered 
service either. 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 pre-approve an 
endosteal implant (D6010) and a bone replacement graft (D4263).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you received three physical 
therapy visits before going into lockdown. You say that you would like the copayments to be covered under the 
cost sharing program. The Plan denied your request. The Plan says the copayments applied 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 $35 
copayment for each Medicare-covered physical therapy and speech-language therapy visit. 
 
You have been asked to pay a $35 copayment for each physical therapy visit. The total amount you owe is 
$105 ($35/visit x 3 visits = $105). Physical therapy falls within the "Outpatient Rehabilitation 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 physical therapy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract laser surgery provided on June 16, 2020. 
 
You asked the Plan to pay for cataract laser surgery. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 cataract laser surgery provided on June 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have no help for 
transportation. The Plan denied your request. The Plan says that your request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to cover routine transportation above the benefit maximum of sixty (60) routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional 
routine transportation trips.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the exchange of nephrostomy catheter provided on 
April 23, 2020. 
 
You asked the Plan to waive the deductible for the exchange of nephrostomy catheter. You say that you 
disagree with the charges because you should not owe anything. The Plan denied your request. The Plan says 
that 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. Your 
contract with the Plan says that enrollees must pay a $0 copayment for outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers.  
 
The record shows that you are enrolled in a Qualified Medicare Beneficiary Plus plan. Therefore, you cannot 
be asked to pay a deductible, copayment or coinsurance.  
 
The Plan says you must pay a $155.52 deductible for the exchange of nephrostomy catheter. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 for the exchange of nephrostomy catheter. 
Therefore, we decided that the Plan has to waive the deductible for the exchange of nephrostomy catheter 
provided on April 23, 2020.  
 
 
 
 
 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laser eye surgery. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the 
Plan and this service could have been provided within the Plan 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 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 medical services provided on March 13, 2020 
by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 12, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was 
enrolled in a hospice program for this date of service and therefore is not 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 drug testing provided on December 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure (22899). You say that the Intracept procedure is 
necessary for the enrollee's chronic low back pain. The Plan denied your request. The Plan says the Intracept 
procedure is considered experimental and investigational. 
 
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 an Intracept procedure (22899). Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure (22899) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inlyta tablets. 
 
You asked the Plan to pre-approve Inlyta tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Inlyta tablets are not covered under the enrollee's Medicare 
Part B benefit. 
 
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 Inlyta tablets.  
 
Benefits for Inlyta tablets 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 pay for the routine electrocardiogram (EKG) provided on May 11, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the routine electrocardiogram (EKG). You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.  
Therefore, we decided that the Plan does not have to pay for the routine electrocardiogram (EKG) provided on 
May 11, 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 the established patient office or other outpatient visit (99213) 
provided on July 7, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient 
visit (99213) provided on July 7, 2020, by an out of network (OON) provider.