Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the head or brain provided on April 23, 2020. 
 
You asked the Plan to pay for the CT of the head or brain. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment 
of all Medicare covered services related or unrelated to the enrollees terminal condition. 
 
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 CT of the head or brain provided on April 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee. 
 
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is 
not a valid physician order for these supplies. 
 
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 physician order for the supplies provided in this case. Specifically, the 
physician order supplied is dated after the date of delivery for the supplies at issue. 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 the diabetic supplies provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are required. The enrollee does not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until the 
enrollee is stable to transfer to a lower level of care such as home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold the enrollee harmless for the inpatient hospital care provided from 
October 30, 2019, through November 2, 2019. 
 
You asked the Plan to hold the enrollee harmless for the inpatient hospital care. You say that you are requesting 
a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the 
provider did not request prior authorization of the services rendered as required by their contract. The denial of 
payment is based on violation of their contract obligations. Additionally, the enrollee is not responsible for the 
payment of these services provided.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for inpatient hospital care by the provider. The provider is a contract provider. The 
file does not show that the plan provided notice that the inpatient hospital care would not be covered. Under 
Medicare rules, this means that the inpatient hospital care is considered approved by the plan. Although the 
Plan has stated that the enrollee is not liable for these services provided, it has not provided evidence that the 
facility was contacted to ensure that any outstanding bills are reversed. Therefore, we decided that the Plan has 
to hold the enrollee harmless for the inpatient hospital care provided from October 30, 2019, through 
November 2, 2019.  
 
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 selective catheter placement (36011) provided on May 12, 
2020. 
 
You asked the Plan to pay for the selective catheter placement. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36011 is selective catheter placement, venous system; 
first order branch (eg, renal vein, jugular vein). 
 
We asked our coder 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 selective catheter placement. Our reviewer says that CPT 
code 36011 does not meet criteria for billing or reimbursement considerations. Our reviewer found Vena Cava, 
is considered "Central Veins", then proceeds to the first order branch. The operative report documents Vena 
Cava only, therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the selective catheter placement have not been met. Therefore, we decided that 
the Plan does not have to pay for selective catheter placement (36011) provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from June 12, 2020, through 
July 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says these 
services must have approval before they are received. 
 
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 physician's services provided from June 12, 2020, through July 
14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes 
E0971, E0966, E0973, E0990, E0978, E2341, E2601, E2625, E2363 provided to the enrollee on August 22, 
2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says there was no valid physician order for the DME in this case. 
 
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 physician order to support medical necessity for the supplies provided in 
this case. 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 the durable medical equipment (DME) as 
defined by codes E0971, E0966, E0973, E0990, E0978, E2341, E2601, E2625, E2363 provided to the enrollee 
on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered 
from March 16, 2020 to March 17, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the enrollee was not given proper 
care. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $300 copayment for services for outpatient hospital observation.  
 
Review of the file shows that the enrollee received hospital outpatient observation services from March 16, 
2020 to March 17, 2020. The enrollee has been asked to pay a $300 copayment for these services. these 
services fall within the outpatient hospital observation benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the outpatient hospital services rendered from March 16, 2020 to March 17, 
2020.  
 
Your complaint about the provider 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from SNF care. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
August 14, 2020. 
 
You asked the Plan to pay for the dental services. You say that you already put in a grievance. You say that you 
were given the wrong information by a plan representative. You say that you have been with this Plan for a 
long time and have never had any trouble. You also say that these services should be covered. The Plan denied 
your request. The Plan says the provider in this case is not a network provider. The Plan says that dental 
services that you receive out of network 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. 
 
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 oral 
exam (D0120) and prophylaxis (D1110) provided on August 14, 2020.  
 
Your complaints about having to call multiple times and being misinformed aby a plan representative are 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral 
periapical x-ray provided on May 21, 2019. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that the provider told you that these 
services would be covered. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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. The contract clearly states that the only covered x-rays under your 
benefit are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral 
periapical x-ray and additional intraoral periapical x-ray provided on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220), the crown (D2740), and the 
filling (D2392) provided. 
 
You asked the Plan to pay for the dental services. You say that the services you received were in response to an 
emergency. You say that the corner of one of your molars had chipped off. You also say that prior to this, you 
had switched plans and had not had the opportunity to establish a relationship with a local dentist in your new 
network. The Plan denied your request. The Plan says the provider in this case is not a network provider. The 
Plan says that there was adequate time to find an in network provider between signing up for the plan and 
receiving these services. The Plan also says that services that you receive out of network 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. 
 
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 
periapical x-ray (D0220), the crown (D2740), and the filling (D2392) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided. 
 
You asked the Plan to pay for the refraction. You say that the ophthalmologist advised you there was no charge 
for this visit. The Plan denied your request. The Plan says this service was not performed during a routine eye 
exam. 
 
Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine 
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The contract with the Plan says that eye refractions are covered during a routine exam. The medical 
diagnosis on the claim for the eye refraction is non exudative age-related macular degeneration, therefore not a 
routine exam. Therefore, we decided that the Plan does not have to pay for the refraction provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Polar Care Cold Therapy Knee unit rendered on June 23, 
2020. 
 
You asked the Plan to pay for these services. You say that you thought this was covered after surgery. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump will be denied 
as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a fluid circulating cold pad. These services 
are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay 
for the Polar Care Cold Therapy Knee unit rendered on June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for bilateral knee pain under 
moderate sedation. 
 
You asked the Plan to pre-approve a genicular nerve block for bilateral knee pain under moderate sedation. 
You say that the requested genicular nerve block for bilateral knee pain under moderate sedation is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block for bilateral knee 
pain under moderate sedation 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 a genicular nerve block for bilateral 
knee pain under moderate sedation. Our reviewer says that the requested genicular nerve block for bilateral 
knee pain under moderate sedation is not medically necessary. Our physician reviewer found the enrollee has 
chronic bilateral knee pain due to osteoarthritis. She is taking an NSAID for pain. She is not a surgical 
candidate due to morbid obesity. She has had intra-articular steroid injections and physical therapy.  
 
The requested genicular nerve blocks are considered experimental/investigational and is the subject of on-going 
clinical trials.  Therefore, the request is considered not medically reasonable or necessary 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 a genicular nerve block for bilateral knee pain under moderate sedation have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for bilateral 
knee pain under moderate sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out 
of network (OON) provider. 
 
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 services were 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 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 31, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and the 
incisional biopsy of oral tissue (D7286) provided. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the comprehensive periodontal evaluation is not listed as a covered service. The 
Plan says that the incisional biopsy of oral tissue is 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. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) and the incisional biopsy of oral tissue (D7286) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5257) and an ear insert (V5264) purchased 
on February 25, 2020. 
 
You asked the Plan to pay for a hearing aid and an ear insert. You say that you thought you would be 
reimbursed for the hearing aid. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays an 
unlimited allowance towards 2 hearing aids every 3 years.  
 
We looked at the case file and the Plan's rules. The Plan has documented that you have already purchased 2 
hearing aids within the past 3 years. Based on this information, we decided that the Plan's rules for coverage of 
a hearing aid and an ear insert have not been met. Therefore, we decided that the Plan does not have to pay for 
a hearing aid (V5257) and an ear insert (V5264) purchased on February 25, 2020.  
 
Your complaint about receiving erroneous or misleading coverage information 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.