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

 
We decided that the Plan does not have to pre-approve core build up (D250) for tooth # 20. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan 
denied your request. The Plan says core build up 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. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-
approve core build up (D250) for tooth # 20.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered from June 19, 
2020 to August 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-plan provider. 
 
The Plan must follow Medicare rules. The rules say that a licensed professional counselor is not eligible to 
enroll in Medicare. 
 
We looked at the file and Medicare rules. The services were rendered by a licensed professional counselor. 
This provider type is not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to 
pay for the outpatient mental health services rendered from June 19, 2020 to August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this service is considered experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. In this circumstance 
therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one 
randomized prospective 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. Our physician reviewer found that 
your condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMems device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 
You asked the Plan to pre-approve the compression stockings. You say that your physical therapist 
recommends compression stockings. The Plan denied your request. The Plan says compression stockings do 
not meet the definition of being durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound.  
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided July 17, 2020, through July 
19, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the services could have been rendered in an observation level 
of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the records show that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, it was reasonably 
expected the inpatient stay would span two midnights. Therefore, we decided that the Plan has to pay for the 
acute inpatient hospital care provided July 17, 2020, through July 19, 2020.  
 
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, preventive procedure, and resin-based 
composite provided on August 17, 2020. 
 
You asked the Plan to pay for the prophylaxis, preventive procedure, and resin-based composite. You say that 
you have a primary insurance, which was terminated on May 31, 2020. The Plan denied your request. The Plan 
says your annual $500 dental benefit was 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, the Plan offers a $500 allowance each 
year for non-Medicare covered dental benefits. The record shows that you met the annual maximum benefit on 
July 23, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the prophylaxis, preventive procedure, and resin-based composite provided on August 17, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81219, 81402 and 81403). 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says the records show that the initial 
JAK2 point mutation testing was positive. 
 
The Plan follows Medicare rules. Medicare rules say that for laboratories performing single gene technologies, 
a sequential genetic testing approach is expected. Once a positive result is obtained and the appropriate 
diagnosis is established, further testing should stop. 
 
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 genetic testing. Our reviewer says 
that The documentation does not support that a sequential genetic testing approach is being followed as 
established by the LCD. Our physician reviewer found the case file does not contain results of BCR/ABL 
testing. Since the JAK2 testing was positive, JAK2 exon 12, CALR and MPL are not covered. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81219, 81402 and 81403).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide provided on July 15, 2020. 
 
You asked the Plan to pay for a stair glide. You say that you were told that half the cost would be reimbursed to 
you. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 pay for a stair glide provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), the crowns, porcelain 
fused to high noble metal (D2750 x 2), and the unspecified adjunctive procedures (D9999 x 2) provided from 
October 29, 2019, to November 21, 2019. 
 
You asked the Plan to pay for the dental services. You say that you were not satisfied with the services you 
received in November and December 2019. You say that you were only supposed to get 1 crown replaced. You 
say that the dentist drilled into the tooth next to the crown to fit 2 crowns. You say that you had to go back to 
get the crowns shaved because they were too big. You also say that now CareCredit wants you to pay $3,000 to 
the provider. The Plan denied your request. The Plan says there is a $460 copayment for each crown, 3/4 cast 
high noble metal or titanium. The Plan says that the gingival irrigation and unspecified adjunctive services are 
not listed as covered. The Plan also says that you signed a treatment plan accepting responsibility for the cost 
of dental services and accepting the amounts being charged to a CareCredit account. 
 
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, each crown, 3/4 cast high noble metal 
or titanium, has a $460 copayment. This is a contractual obligation you agreed to when you enrolled in the 
Plan?s dental coverage. Additionally, the gingival irrigation and unspecified adjunctive procedures are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921 x 4), the crowns, porcelain fused to high noble metal (D2750 x 2), and the 
unspecified adjunctive procedures (D9999 x 2) provided from October 29, 2019, to November 21, 2019.  
 
 
 
Your complaint about not being satisfied with the services you received is not a valid appeal for 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 waive the cost sharing for the orthopedic office visit provided along 
with a hip x-ray on September 29, 2020. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you feel that the additional 
copayment should be waived. The Plan denied your request. The Plan says your contract indicates that there is 
a copayment for a specialist office visit and that other copayments may also be 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 covered visits in an outpatient setting with a specialist.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the covered visits 
in an outpatient setting with a specialist benefit category. This would correctly be applied along with the $10 
copayment for the radiology services. 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 provided along with a hip x-ray on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omeprazole. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 omeprazole.  
 
Benefits for these services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prempro tablets. 
 
You asked the Plan to pre-approve Prempro tablets. You say that the enrollee has been on this medication for 
years. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug 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 Prempro tablets.  
 
Benefits for Prempro tablets 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 periodontal maintenance (D4910) provided on September 
8, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like this claim covered and 
approved for payment. The Plan denied your request. The Plan says this is not a covered service according to 
your 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 pay for the 
periodontal maintenance (D4910) provided on September 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
on October 5, 2020, and October 19, 2020. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you feel that a 
copayment is not warranted. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 outpatient rehabilitation services.  
 
You received outpatient rehabilitation services on October 5, 2020, and October 19, 2020. Therefore, you are 
responsible to pay a $30 copayment per each visit. The total amount you owe is: $60.  
 
You have been asked to pay the total copayment amount of $60 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient 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 copayments for outpatient rehabilitation services provided on October 5, 2020, and 
October 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services and diagnostic radiology services 
provided on September 25, 2019. 
 
You asked the Plan to pay for the emergency room services and diagnostic radiology services. The Plan denied 
your request. The Plan says the member was enrolled in hospice. 
 
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 emergency room services and diagnostic radiology services 
provided on September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided 
September 15, 2020, to September 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the cost share has 
applied correctly in this case. 
 
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 $325 
copayment per day for days 1-5, $0 copayment per day for days 6 and beyond for inpatient hospital care.  
 
You have been asked to pay a total cost share of $960 for the inpatient hospital care (3 inpatient days x $325 
copayment = $960). The services provided fall within the inpatient hospital 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 the inpatient hospital care provided September 15, 2020, to 
September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services on August 11, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for physician 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services on August 11, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shingrix vaccine. 
 
You asked the Plan to pre-approve Shingrix vaccine. You say that you doctor is telling you to get this to 
prevent getting shingles. The Plan denied your request. The Plan says the denial of authorization for this 
immunization is correct, because this vaccine is not covered by Medicare Part B and the Plan does not 
administer your Medicare Part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Shingrix vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Shingrix vaccine. 
Therefore, we decided that the Plan does not have to pre-approve a Shingrix vaccine.  
 
Benefits for Shingrix vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.