Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current acute care facility. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19, requiring high 
flow oxygen, antibiotics, steroids, physical therapy, with recent notable improvements in oxygen requirements 
and mobility. The enrollee appears to be more stable and requires less than an additional 25 days of acute care 
services, based on the recent notes. The enrollee does not require services at the LTACH that are not already 
available at the current setting. Therefore, this request for LTACH services will be considered not medically 
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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a prosthesis with an out-of-network DME 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this provider has assisted you for 10 years. The 
Plan denied your request. The Plan says the requested DME provider is not participating. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for a prosthesis with an out-of-network DME provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on February 24, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should have a $0 copayment 
for vision services. 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 $155 
copayment for outpatient diagnostic tests/radiological diagnostic service.  
 
You have been asked to pay $88.90 which is less than your copayment amount of $155 for an ultrasound. An 
ultrasound falls within the outpatient diagnostic tests/radiological diagnostic service 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 ultrasound provided by a participating provider on 
February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on June 2, 2020. 
 
You asked the Plan to pay for the extraction. You say that the provider would like to change the extraction code 
from D7210 to D7140. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental 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 for the 
extraction (D7210) provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on June 22, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that the Plan pays up to $1,000 per year for 
covered preventive and comprehensive dental services. You also say that you did not know that you needed to 
purchase a rider for these services to be covered. The Plan denied your request. The Plan says these services are 
not covered benefits under your dental 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 for the crown 
(D2740) and core buildup, including any pins when required (D2950) provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on May 19, 2020. 
 
You asked the Plan to pay for the extraction. You say that you feel this was emergency treatment. The Plan 
denied your request. The Plan says your contract does not cover this service. The Plan also says that you do not 
have optional supplemental dental coverage. 
 
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 
extraction provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) and bitewing x-ray 
(D0274) provided on June 16, 2020. 
 
You asked the Plan to pay for the intraoral x-rays (D0220 and D0230) and bitewing x-ray (D0274). You say 
that you shouldn't have to pay for x-rays that they took. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-rays (D0220 and D0230) and bitewing x-ray (D0274) provided on June 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that additional trips are needed to get to 
medical appointments. The Plan denied your request. The Plan says the service is a covered benefit, but the 
enrollee has exceeded 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 60 one-way 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 trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on February 5, 2020. 
 
You asked the Plan to pay for the dental services. You say that you received conflicting information from the 
plan. You say that that no matter which plan you have, periodontal exams and x-rays are covered with a $0 
copayment. You also say that the services should be covered. The Plan denied your request. The Plan says 
comprehensive oral evaluation is not listed as a covered service. The Plan says bitewing x-rays are 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 dental services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and bitewing x-rays (D0274) provided on February 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 104 individual psychotherapy sessions and 104 family 
psychotherapy sessions. 
 
You asked the Plan to pre-approve the psychotherapy visits. You say that you request help in overturning this 
adverse determination as soon as possible in order for this enrollee to begin treatment at once. The Plan denied 
your request. The Plan says the provider did not send documentation showing why the additional sessions and 
family sessions are needed. 
 
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 psychotherapy visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review the records provided, upon discharge from his recent inpatient stay 
the enrollee was referred to the non-network therapist due to the ability to use American Sign Language. Since 
this enrollee had been seeing the psychotherapist, she has been inherent to medication and has been stable. In 
reviewing the enrollee's records there is no clear documentation has taken place in the therapy sessions. It is 
unclear why increase number of sessions is required as the enrollee has been stable on the current number of 
sessions provided. Based on review the records provided it appears reasonable for the medical plan to utilize 
the generous amount of psychotherapy sessions which includes 52 individual psychotherapy sessions up to one 
hour each and 1 diagnostic session. It is unclear why this enrollee requires 104 family sessions. 
 
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 psychotherapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 104 individual psychotherapy sessions and 104 family psychotherapy sessions.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 27, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
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 
physician services provided to the enrollee on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene analysis of prostate tumor tissue (81551) provided 
on February 19, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the gene analysis of prostate tumor tissue. 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 gene analysis of prostate tumor tissue (81551) provided on February 19, 
2019, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the orthopedic office visit and the Gel-
One injections you received on June 2, 2020. 
 
You asked the Plan to waive the cost sharing for the orthopedic office visit and the Gel-One injections. You say 
that because you got no relief from these injections, you shouldn't have to pay the bill. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 $25 
copayment for specialist visits and 20% coinsurance for Medicare-covered Part B drugs.  
 
Records show that you had an office visit with an orthopedist (a specialist) on June 2, 2020. During that office 
visit, you received Gel-One injections. You have been asked to pay a $25 copayment for the office visit and 
20% coinsurance for the orthopedic office visit and the Gel-One injections. These cost sharing amounts apply 
regardless of whether the drug is helpful for you. 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 cost sharing for 
the orthopedic office visit and the Gel-One injections you received on June 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for outpatient hospital services and self-
administered drugs provided April 18, 2020, to April 20, 2020. 
 
You asked the Plan to waive the cost-sharing for the outpatient hospital services and self-administered drugs. 
You say that the service should have been billed as an inpatient hospital stay. The Plan denied your request. 
The Plan says the correct cost-sharing was applied. The record shows the services were outpatient. 
 
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 $400 
copayment for outpatient observation services after the $1,000 deductible is met. Medicare rules say that Self-
administered drugs provided in the outpatient setting are not covered under the Part B medical benefit. 
 
You have been asked to pay the remaining balance of the $1,000 deductible ($799.34) and a $400 copayment 
for the outpatient hospital services. You have also been asked to pay for the non-covered self-administered 
drugs. 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 cost-sharing for outpatient hospital services and self-
administered drugs provided April 18, 2020, to April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
the bitewing x-rays (D0274), the filling (D2392) for tooth # 3, and the filling (D2332) for tooth # 9 provided 
from March 3, 2020, to June 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider was covered when you bought the 
policy. You also say that now he is not. The Plan denied your request. The Plan says the provider in this case is 
not a network provider. The Plan says care rendered by a provider that is not part of our supplemental dental 
network is 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, dental services that you receive out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), the filling 
(D2392) for tooth # 3, and the filling (D2332) for tooth # 9 provided from March 3, 2020, to June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), crown 
(D2740), and core buildup, including any pins when required (D2950) provided on June 22, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, crown, and core buildup. You say 
that you contacted the health plan and were told that you had coverage for these dental services. You also say 
that the dentist office was told that you were not covered. The Plan denied your request. The Plan says these 
services are not covered under your dental plan. The Plan also says that it was verified that no misinformation 
was given. 
 
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 
problem focused limited oral evaluation (D0140), crown (D2740), and core buildup, including any pins when 
required (D2950) provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on July 6, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that your primary care office was 
closed due to COVID-19, so you had to go to urgent care. The Plan denied your request. The Plan says you 
were charged this copayment 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 $65 
copayment for urgent care.  
 
You have been asked to pay a $65 copayment for the urgent care visit. This copayment applies regardless of 
the reason for the urgent care visit. 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 urgent care visit 
you had on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 22, 
2020. 
 
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says the provider in 
this case is not a network provider. The Plan says that if you receive care from an out of network dental 
provider you must pay for your own care. 
 
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, dental services that you receive out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the periodontal maintenance (D4910) provided on June 22, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the medical records provided support 
the need for the requested device. The Plan denied your request. The Plan says medical studies have not proven 
that the device is helpful for the treatment of the enrollee's health problem. 
 
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 CardioMEMs device. Our reviewer 
says that a CardioMEMs device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. The device should still be considered 
experimental or investigational. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.