Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound dressing provided on October 27, 2020. 
 
You asked the Plan to pay for the wound dressing. The Plan denied your request. The Plan says the service is 
part of the initial procedure. 
 
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 A6196 is alginate or other fiber gelling dressing, wound 
cover, sterile, pad size 16 sq. in. or less, each dressing 
 
We find that CPT code A6196 is a bundled procedure. If the item or service is covered as incident to a 
physician service and is provided on the same day as a physician service, payment for it is bundled into the 
payment for the physician service to which it is incident.  Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the wound 
dressing provided on October 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from February 19, 2020, to 
February 26, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the Plan had authorized your SNF stay. The Plan 
denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 53 days of SNF care through December 31, 2019, and had received a total of 
100 days of SNF care on February 18, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for the SNF services provided from February 19, 2020, to February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision services provided by a participating 
provider on December 10, 2020. 
 
You asked the Plan to waive the copayment for vision services. You say that the doctor did not take off the skin 
tag and that was the only reason for this appointment. 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 $30 
copayment for vision care/eye exam.  
 
You have been asked to pay a $30 copayment for vision services. Since an office visit took place, the correct 
copayment has been applied. Vision services falls within the vision care/eye exam 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 vision services provided by a participating provider on December 10, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eye glass frames and lenses purchased on 
November 25, 2020. 
 
You asked the Plan to reimburse you for eye glass frames and lenses. You say that you were not under the 
impression if you were to use the reimbursement form you would not get any money back. The Plan denied 
your request. The Plan says the eyewear you received was not related to cataract surgery. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The eyewear you asked the Plan to reimburse you for are not considered cataract surgery eyewear. Therefore, 
we decided that the Plan does not have to reimburse you for eye glass frames and lenses purchased on 
November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has tried medication 
management, and injections with no relief. The Plan denied your request. The Plan says there are not enough 
studies to show the Vertiflex is safe and effective to treat back pain. 
 
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 requested device. Our physician 
reviewer found that the requested device is experimental. More research is needed to show safety and efficacy 
of the device. Therefore, the requested interspinous spacer device is 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on 
November 9, 2020. 
 
You asked the Plan to waive the copayment for the visual field exam. You say that there was no copayment 
required by the front desk when you finished the test. You say that this appointment was broken into two 
different dates so you should not be billed for another copayment. The Plan denied your request. The Plan says 
the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for an in-network specialty physician for other Medicare-covered outpatient diagnostic tests. 
 
You have been asked to pay a $45 copayment for the visual field exam. The visual field exam falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that 
services were provided on separate dates of service. 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 visual field exam provided on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not a covered 
drug under the enrollee's Part B 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 Xiidra.  
 
Benefits for Xiidra 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 core buildup, including any pins when required provided on October 30, 2020.
You asked the Plan to pay for the core buildup. You say that you were advised that this provider was in-network. The Plan denied your request. The Plan says this service 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, 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 core buildup, including any pins when required provided on October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation 
benefit. 
 
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.  
 
We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we 
decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your 
request submitted to the Plan was for an additional 80 trips, 140 trips in total. However, the Plan contract 
provides coverage for 60 one-way trips only per calendar year. Your request exceeds the allowable 
transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional trips for 
routine transportation (A0120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol. 
 
You asked the Plan to pre-approve Dronabinol. The Plan denied your request. The Plan says this drug is not 
covered under your Part B 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 Dronabinol.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on April 10, 2020 
and bone imaging provided on April 22, 2020. 
 
You asked the Plan to waive the copayment for the CT scan and bone imaging. You say that you had tests in 
the past and did not have copayments. The Plan denied your request. The Plan says the copayments applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $300 copayment for the CT scan and a $300 copayment for the bone imaging. 
The CT scan and bone imaging fall 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 the CT scan provided on 
April 10, 2020 and bone imaging provided on April 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Humalog. 
 
You asked the Plan to pay for Humalog. The Plan denied your request. The Plan says this drug it not covered 
under the enrollee's Part B 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 pay for Humalog.  
 
Benefits for Humalog 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 pre-approve a porcelain crown (D2740) and core build up (D2950) 
for tooth # 14. 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that 
core build up 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 pre-approve a 
porcelain crown (D2740) and core build up (D2950) for tooth # 14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648) provided October 13, 
2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that these items should be covered. The Plan 
denied your request. The Plan says the documentation does not support the request. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records also do not indicate that the items at issue were prescribed in connection to a 
valid telehealth visit with the enrollee's treating physician. 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 lumbar-sacral orthosis (L0648) provided October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revo system adjustable socket. 
 
You asked the Plan to pre-approve revo system adjustable socket. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 revo system adjustable socket. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has undergone anatomical changes.  The enrollee is no longer 
fitting in the prostheses. The RevoFit socket is not medically necessary. There is no evidence of long-term 
effectiveness and safety in the literature for the use of the RevoFit therefore, this request is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revo system adjustable socket have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revo system adjustable socket.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning (D1110) provided on December 1, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were told by a couple of representatives that 
you are allowed 3 dental cleanings per year. You say that you were transferred to a representative in the dental 
department and were advised there were 2 different types of cleanings. You say that you feel that the cleaning 
should be covered as you were given incorrect information. You also say that you get cleanings every 4 months 
due to periodontal disease and gingivitis. The Plan denied your request. The Plan says cleanings are covered 
twice every plan year. The Plan says that the frequency limit for this service has been exceeded. 
 
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 cleanings are listed as a covered 
service, the frequency limit has been exceeded. The record shows that the Plan paid for cleanings that you 
received on March 10, 2020, and July 28, 2020. Therefore, we decided that the Plan does not have to pay for 
the cleaning (D1110) provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup procedure (D2950) for tooth number 15. 
 
You asked the Plan to pre-approve a core buildup procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's 
supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup procedure (D2950) for tooth number 15.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating 
provider on November 24, 2020. 
 
You asked the Plan to waive the copayment for an injection. You say that you had to get this done at the 
hospital due to the Covid-19 pandemic. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment for outpatient surgery/in-network/outpatient hospital.  
 
The enrollee has been asked to pay a $325 copayment for an injection. The injection that you received is 
considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within 
the outpatient surgery/in-network/outpatient hospital 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 an injection provided by a participating provider on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 2), biologic materials to aid in soft and osseous tissue regeneration (D4265 x 2), semi-precision attachment abutment (D6025 x 3), and the bone graft at the time of implant placement (D6104 x 4).
You asked the Plan to pre-approve the dental services. You say that the services have been requested as they are medically necessary. You also say that you feel these services are necessary to the enrollee's dental treatment. The Plan denied your request. The Plan says the requested dental services are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 2), biologic materials to aid in soft and osseous tissue regeneration (D4265 x 2), semi-precision attachment abutment (D6025 x 3), and the bone graft at the time of implant placement (D6104 x 4).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0156) provided September 14, 2020 
to September 18, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services 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. 
 
We find that CPT code G0156 is not supported in the medical record. Specifically, the documentation does not 
note the time spent on the services. Based on this information, we decided that Medicare rules for coverage of 
the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services (G0156) provided September 14, 2020 to September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that this procedure is covered by Medicare 
for the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this procedure is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental/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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.