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

 
We decided that the Plan does not have to pay for the resin-based composite, crown, and core buildup, 
including any pins when required provided on July 7, 2020. 
 
You asked the Plan to pay for the resin-based composite, crown, and core buildup. You say that you were 
advised that you would have to pay $543.75 for these services, but were later advised that these services were 
denied. The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says 
that you were presented with and signed a treatment plan that shows your responsibility for these services 
would be $543.75. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plan says that if you have already paid the $543.75 for these 
services, you do not owe any additional payment. Therefore, we decided that the Plan does not have to pay for 
the resin-based composite, crown, and core buildup, including any pins when required provided on July 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment a Medicare-covered eye exam provided on 
June 17, 2020. 
 
You asked the Plan to waive the copayment the Medicare-covered eye exam. You say that you had a routine 
eye exam and you were not diagnosed or treated. The Plan denied your request. The Plan says you had a 
medical eye exam for a pre-existing condition of nuclear cataracts in both eyes for a 14 month follow up. 
 
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 $40 
copayment for Medicare-Covered Vision Care.  
 
You have been asked to pay $40 copayment for the Medicare-covered eye exam. the Medicare-covered eye 
exam falls within the Medicare-Covered Vision 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 a Medicare-covered eye exam provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit, an EKG, and an 
ultrasound provided by a participating provider on February 6, 2020, to February 21, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit, an EKG, and an ultrasound. You say 
that you never asked for these services. The Plan denied your request. The Plan says the correct copayments 
have 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 $45 
copayment for physician/practitioner services/in-network specialist, a $30 copayment for outpatient diagnostic 
tests/in-network/non-radiological services, and a $160 copayment for outpatient diagnostic tests/in-
network/radiological services.  
 
You have been asked to pay a $45 copayment for a specialist office visit, $14.90 which is less than your 
copayment amount of $30 for an EKG, and a $160 copayment for an ultrasound. The total amount you are 
being asked to pay is $219.90 ($160 + $45 + $14.90 = $219.90). A specialist office visit falls within the 
physician/practitioner services/in-network specialist benefit category. An EKG and an ultrasound falls within 
the outpatient diagnostic tests/in-network/non-radiological services and outpatient diagnostic tests/in-
network/radiological 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 a specialist office visit, an EKG, and an ultrasound provided 
by a participating provider on February 6, 2020, to February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services (0124, 0250, 0270, 0300, 
0730) provided on December 13, 2019, to December 31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient mental health services. 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 inpatient mental health services (0124, 0250, 
0270, 0300, 0730) provided on December 13, 2019, to December 31, 2019 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand in the bath tub for a 
long period of time. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 10 and 11 provided on June 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not notified that you were not covered 
by the insurance form comprehensive dental services. You say that you were not notified that the fillings would 
be not be covered. You say that the comprehensive coverage is pretty much what your coverage was last year. 
You also say that you should not have to pay for the fillings. The Plan denied your request. The Plan says you 
do not have the optional benefit that covers comprehensive dental services for this date of service. The Plan 
also says that fillings are 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, you were not enrolled in the Optional 
Supplemental Dental Services on the date of service. Therefore, we decided that the Plan does not have to pay 
for the fillings for teeth # 10 and 11 provided on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog. 
 
You asked the Plan to pre-approve Novolog. You say that the enrollee has been taking Novolog for years. The 
Plan denied your request. The Plan says the self-administered medication is not covered by the enrollee's 
medical 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 Novolog.  
 
Benefits for Novolog 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 15 minutes of deep sedation (D9223 x 13) 
provided on March 5, 2020. 
 
You asked the Plan to pay for the dental service. You say that the enrollee got implants. You say that this 
service should be covered under the enrollee's medical coverage, not dental. You also say that anesthesia 
should be covered regardless of the procedure or circumstance. The Plan denied your request. The Plan says the 
deep sedation is dental in nature. The Plan also says that deep sedation is not listed as 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional 15 minutes of deep sedation (D9223 x 13) provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter purchased on April 21, 2020. 
 
You asked the Plan to pay for the power scooter. You say that you were told you could purchase the scooter 
and then submit for reimbursement. The Plan denied your request. The Plan says that you received the scooter 
from a non-Medicare provider. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the power scooter purchased on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided October 7, 2019. 
 
You asked the Plan to pay for the office visit. You say that no payment has been paid to this claim and you 
would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says the plan is 
secondary and the primary insurance payers EOB is needed in order to process the claim for these service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the enrollee has an active 
primary insurance with another plan and the claim needs to be submitted to them before the plan can process 
the claim. As the secondary insurer, the Plan cannot be held responsible for the office visit until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99214) provided October 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services at a high complexity 
level. 
 
You asked the Plan to pay for the emergency department services (99285). You say that the Plan should pay 
this claim at the high complexity level. The Plan denied your request. The Plan says the records do not support 
a high complexity level of service therefore the claim was down-coded to 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the medical records provided 
do not sufficiently support the billing of code 99285 as it appears further evaluations and surgical consults were 
to be performed once the enrollee was admitted as inpatient. Based on this information, we decided that 
Medicare rules for coverage of the emergency department services (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department services at a high complexity level.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary EOB is 
needed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you have received conflicting opinions from 
local surgeons. The Plan denied your request. The Plan says consult office visits can be rendered by in-plan 
providers. 
 
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 office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 
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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require 
ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 
the last covered date.  The enrollee does not have complex wound care or other ongoing SNF level SN need. 
The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge 
and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF beyond the last covered date. The enrollee does not require skilled nursing or skilled 
therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this 
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting 
beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injection in each knee. 
 
You asked the Plan to pre-approve Zilretta injections. You say that you want to be treated with this drug 
because it works for you. The Plan denied your request. The Plan says the enrollee has not first tried and failed 
to have an adequate response to at least one other intra-articular corticosteroid injection and you have already 
received a Zilretta injection therefore authorization for repeat administration of Zilretta for either knee cannot 
be provided. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Zilretta injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found Ziltetta remains experimental for 
knee pain. 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 Zilretta injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zilretta injection in each knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 
14061 provided on May 13, 2020. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 14061 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips, for 
defects 10.1sq cm to 30.0 sq cm. Based on this information, we decided that Medicare rules for coverage of the 
adjacent tissue transfer or rearrangement services have not been met. Therefore, we decided that the Plan does 
not have to pay for the adjacent tissue transfer or rearrangement services coded 14061 provided on May 13, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and backpack holder.

You asked the Plan to pre-approve the requested items. You say that the elevation component allows you to transfer from the bed to the toilet, and the backpack holds your essential tools. The Plan denied your request. The Plan says the items are not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and backpack holder.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on June 5, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you had two MRIs done at the same time 
on the same body. You say that you should only have to pay one $100 copayment. 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 $100 
copayment for outpatient diagnostic tests/MRI.  
 
You have been asked to pay a $100 copayment for an MRI. There is a $100 copayment for each MRI that is 
provided; therefore, the correct copayment has been applied. An MRI falls within the outpatient diagnostic 
tests/MRI 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 MRI provided by a 
participating provider on June 5, 2020.