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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you were advised that the plan covers deep 
cleaning when you are enrolled. You say that the plan should honor what he was told and cover the deep 
cleaning. You also say that you have been trying to get this done since the beginning of COVID-19. The Plan 
denied your request. The Plan says periodontal scaling and root planing is not a covered service. 
 
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 periodontal scaling and 
root planing is not among those covered under this benefit. The Evidence of Coverage clearly states that 
periodontal scaling, root planning and periodontal maintenance are excluded from coverage. Therefore, we 
decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on June 26, 
2019. 
 
You asked the Plan to pay for the ambulance services. You say that the claim does not require prior 
authorization. The Plan denied your request. The Plan says the trip was not scheduled through the plan. 
 
Medicare rules say that plans can require authorization before receiving services. The contract with the Plan 
says that Prior authorization is required for in-network and out-of-network non-emergent ambulance services to 
be sure the services meet Medicare-coverage guidelines. 
 
We looked at the file and the rules. 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 ambulance transportation services provided on June 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
criteria for an LTACH stay and will likely need this level of care for another 25 days. The Plan denied your 
request. The Plan says there is no reason that an LTACH would be able to provide better care than continued 
care in a short-term care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided requiring admission to a LTACH. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that you have never received a denture before. The 
Plan denied your request. The Plan says the requested denture is covered once every 60 months. The Plan says 
that you received an upper partial denture on August 23, 2018. The Plan also says that the frequency limit has 
been reached. 
 
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 and dentures are a covered service, the 
frequency limit has been reached. Therefore, we decided that the Plan does not have to pre-approve an upper 
partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breathing capacity test (94010) 
administered on May 7, 2020. 
 
You asked the Plan to waive the copayment for a breathing capacity test. You say that you were not sufficiently 
informed by the provider regarding additional charges. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for a breathing capacity test. A breathing capacity test falls 
within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a breathing capacity test (94010) administered on May 7, 2020.  
 
Your complaint about not receiving sufficient information from 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on February 27, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that you are a contracted provider with the plan. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 office outpatient visit (99214) provided on 
February 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient medical services provided 
May 15, 2020. 
 
You asked the Plan to waive the copayment for the outpatient medical services. You say that you are requesting 
this to be processed as in-network because you went to the walk-in clinic for a COVID test and the billing 
supervisor told you that the COVID test should have been paid as in-network. The Plan denied your request. 
The Plan says this claim was processed correctly and the correct copay was applied per the Evidence of 
Coverage. 
 
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 50% of 
the Medicare allowed amount for out of network primary care provider.  
 
You have been asked to pay $50.78 for the outpatient medical services. The outpatient medical services fall 
within the Physician/Practitioner services, including doctor's office visits 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 the outpatient medical services provided May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy (31231) performed on 
June 10, 2020. 
 
You asked the Plan to waive the copayment for a nasal endoscopy. You say that this visit was strictly a follow-
up exam and you believe the submitted code is incorrect. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center.  
 
You have been asked to pay a $154.96 copayment for a nasal endoscopy. A nasal endoscopy falls within the 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" benefit category. This means that you have been asked to pay less than the full 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 a nasal 
endoscopy (31231) performed on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehab services provided by a 
participating provider from January 2, 2020, to January 30, 2020. 
 
You asked the Plan to waive the copayment for cardiac rehab services. You say that you would like the Plan to 
pay the rest of this bill. 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 $20 
copayment for cardiac rehabilitation services.  
 
You have been asked to pay a $20 copayment for each cardiac rehab services. The total amount you are being 
asked to pay is $180 ($20 x 9 visits = $180). Cardiac rehab services fall within the cardiac 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 cardiac rehab services 
provided by a participating provider from January 2, 2020, to January 30, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa 75mg capsules 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 the enrollee does not have a pharmacy benefit with the plan. 
 
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 Pradaxa 75mg capsules for 
the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on May 1, 
2020 to May 5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says prior authorization was not obtained to utilize an out-of-network provider and there 
were in-network providers in your area able to provide the services rendered. 
 
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 skilled nursing facility (SNF) care provided on 
May 1, 2020 to May 5, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the vascular services. You say that you would like reconsideration because 
these services are medically necessary. The Plan denied your request. The Plan says these services are available 
in 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 medical services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) on June 
5, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you thought the Plan 
waived copayments that related to COVID-19. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
The Plan?s policy relating to waivers of copayments relating to the COVID-19 pandemic clearly states that the 
waiver does not apply to emergency, urgent, and ambulance services. Therefore, you have been asked to pay a 
$90 copayment for an emergency room visit. 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 (99284) 
on June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF services after October 30, 2020. 
 
You asked the Plan to pre-approve the continuation of SNF services after October 30, 2020. The Plan denied 
your request. The Plan says based on Medicare guidelines, the SNF services you and/or your provider are 
requesting do not meet the requirements for approval. 
 
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 the continuation of SNF services after 
October 30, 2020. Our reviewer says that daily skilled services are not medically necessary. Our physician 
reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. 
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the 
SNF. By the dates in question, you were at a minimal to maximal assist level for functional mobility. You 
required varying assist with activities of daily living. You were independent with wheelchair mobility.  There 
 
 
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.  You do 
not require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 the continuation of SNF services after October 30, 2020 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after October 
30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on December 25, 2019, through 
January 2, 2020. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the member's claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. 
 
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 hospital services provided on December 25, 2019, through 
January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided, 
there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this 
case. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee believes that she threw away her 
denture while cleaning. You say that the denture should be approved based on the New York Social Services 
Law 365-a. You also say that the lack of denture has caused the enrollee to lose weight and is preventing her 
from receiving proper nutrition to live. The Plan denied your request. The Plan says dentures are covered once 
every 5 plan years. The Plan says the frequency limit has been reached. 
 
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 and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for dentures 
on June 28, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 1, 
2020 to May 30, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF 
services. The Plan denied your request. The Plan says medical necessity cannot be established for continued 
SNF level of coverage. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided May 1, 2020 to May 30, 2020.