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

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue
regeneration (D3431) for tooth #'s 4, 12, 21, and 28.
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regenerations. You
say that you are not able to pay the dentist, but you do not have a choice not to pay the dentist. You also say
that you broke 2 teeth, and it was suggested by your doctor to go to an endodontist for a root canal. The Plan
denied your request. The Plan says this service is not covered under your benefit package.
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
biologic materials to aid in soft and osseous tissue regeneration (D3431) for tooth #'s 4, 12, 21, and 28.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography Angiography (CTA) of the lower extremity (73706) provided January 24, 2020.
You asked the Plan to pay for the CTA. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a required modifier.
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 73706 is not supported in the medical record. Specifically, the claim did not include a modifier to denote the anatomical location of the CTA performed. Based on this information, we decided that Medicare rules for coverage of the CTA have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography Angiography (CTA) of the lower extremity (73706) provided January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the mastectomy sleeve (L8010) provided September 19,
2019.
You asked the Plan to pay for the mastectomy sleeve. You say that you are appealing denial of coverage for the
arm sleeve and hand glove that you have already paid for. The Plan denied your request. The Plan says this
item is not covered because it does not meet the definition of a prosthesis.
The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeve is not covered because it does
not meet the definition of a prosthesis.
While a mastectomy sleeve may be appropriate in this case, neither the Plan nor Medicare offer coverage of
this item. Based on this information, we decided that Medicare rules for coverage of the mastectomy sleeve
have not been met. Therefore, we decided that the Plan does not have to pay for the mastectomy sleeve (L8010)
provided September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on January 10, 2020 and the resin
based composite provided on January 31, 2020.
You asked the Plan to pay for the prophylaxis and resin based composite. You say that you couldn't find a
place where it stated that the dentist had to be in-network to be covered. You say that the Plan should pay their
allowance for these services. The Plan denied your request. The Plan says the services are not a covered
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. The prophylaxis is only covered when received from an in-network
provider. The resin based composite is not a covered benefit when received from an in-network or out-ofnetwork
provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on
January 10, 2020 and the resin based composite provided on January 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation care
(93306, G0378, 93305, 99285) provided February 16 to February 17, 2020.
You asked the Plan to waive the copayment for the outpatient hospital care. You say that you were admitted as
an inpatient the next day, so the copayment should be waived. The Plan denied your request. The Plan says the
correct copayment was applied for the service rendered.
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 $200
copayment for Outpatient Hospital Facility visits.
You have been asked to pay a $200 copayment for the outpatient hospital care. The outpatient hospital care
falls within the Outpatient Hospital Facility visits benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for outpatient hospital observation care (93306, G0378, 93305, 99285) provided February 16 to
February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty (D7311).
You asked the Plan to pre-approve the alveoloplasty (D7311). You say that the treatment is recommended to
prevent pain and discomfort. The Plan denied your request. The Plan says the service is not a covered 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 the
alveoloplasty (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable gloves (E1399).
You asked the Plan to pre-approve the disposable gloves. You say that you need to have the gloves for your
protection for you to be able to do the essential things. The Plan denied your request. The Plan says this is
considered a convenience item and not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve disposable gloves (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist
device (L8702).
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say
that this device would restore function to the dysfunctional arm and the ability to perform activities of daily
living. The Plan denied your request. The Plan says a review of the current medical literature indicates that this
device is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary, and are experimental and investigational, are not covered.
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by
Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its
effectiveness. Based on this information, we decided that Medicare rules for coverage of a myoelectric elbowwrist-
hand-finger orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve
a powered upper extremity range of motion assist device (L8702).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99213), an
electrocardiogram (93000), and an echocardiogram (93306) provided January 15, 2020.
You asked the Plan to waive the copayments for the office visit, electrocardiogram, and echocardiogram.. You
say that the copayments for the tests should be included in the office visit. The Plan denied your request. The
Plan says each service has a separate copayment. The correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for each specialist visit. There is a $30 copayment for non-radiologic diagnostic tests. There is also
a $160 copayment for Radiology Services.
You have been asked to pay a $45 copayment for a specialist visit, a $160 copayment for an echocardiogram
(this falls within the radiology services benefit category), and a $13.06 copayment for the electrocardiogram
(this falls within the diagnostic tests benefit category). In this case the Medicare allowed amount of $13.06 was
less than the $30 copayment stipulated in the contract. This means that you have been asked to pay the correct
amounts 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 a
specialist office visit (99213), an electrocardiogram (93000), and an echocardiogram (93306) provided January
15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need more therapy. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
services are not medically necessary. Our physician reviewer found you were admitted to the hospital on July
10, 2020 after a fall with a leg fracture. Your pain is now controlled and you are medically stable. You need
assistance with bed mobility, transfers, and walking with a rolling walker. You have no complex issues that
require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or acute
rehab nursing care. You may benefit from further therapy but do not require an intensive therapy program in an
IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with accessories (E1161, K0108,
E2203, E1225, E2609, E1028, E2617).
You asked the Plan to pre-approve the manual wheelchair and accessories. You say that a new wheelchair is
medically necessary. The Plan denied your request. The Plan says wheelchairs are not covered by CMS if they
are standard and can be supplied by a long term care facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the manual wheelchair and accessories is being requested for use in a SNF or hospital.
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with accessories
(E1161, K0108, E2203, E1225, E2609, E1028, E2617).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided on March 12, 2020.
You asked the Plan to pay for the panoramic x-rays (D0330). You say that you are appealing this claim. The
Plan denied your request. The Plan says you have exceeded your maximum benefit limit
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, there is a benefit limit for the
panoramic x-rays (D0330). The plan clearly states that only one set of panoramic x-rays are covered every 5
years. The records show the Plan paid for one set of panoramic x-rays (D0330) on October 18, 2019, which
exhausted the benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-rays
(D0330) provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on March 3, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you feel that you should only owe a
$65 copayment. 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 $65
copayment for each diagnostic procedure or test provided in a network doctor's office and a $235 copayment
for each diagnostic procedure or test provided in a network outpatient facility.
You received a CT scan at an outpatient hospital facility on March 3, 2020. Therefore, you are responsible to
pay the allowed amount of $173.08, which is less than the $235 copayment.
You have been asked to pay $173.08 for a CT scan. A CT scan falls within the outpatient diagnostic tests and
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a
CT scan provided on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee is status post-surgery with no recent neurological events with no
complications. The enrollee required moderate assistance for mobility. The documentation does not support
that the enrollee requires monitoring by inpatient physical medicine and rehabilitation physician three times per
week or the need for acute rehabilitation nursing care. The documentation does not support that the enrollee
requires treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. The enrollee may benefit from further physical therapy and
occupational therapy, but does not require an intensive therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral examination (D0120) and periapical x-rays (D0220,
D0230) provided by on December 18, 2019 to March 17, 2020.
You asked the Plan to pay for the oral examination (D0120) and the periapical x-rays (D0220, D0230). You
say that you are appealing the denials because of the Plan's new rule that it is 12 months of service and not the
contract year. The Plan denied your request. The Plan says you have exceeded your maximum benefit limit.
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, there is a benefit limit for the oral
examinations and periapical x-rays. The Plan clearly states that only two oral examinations are covered per
calendar year. The Plan clearly states that four periapical x-rays are covered in a 12-month period. The records
show the Plan paid for one oral examination and two periapical x-rays on March 20, 2019 and one oral
examination and two periapical x-rays on June 13, 2019, which exhausted the benefit. Therefore, we decided
that the Plan does not have to pay for the oral examination (D0120) and the periapical x-rays (D0220, D0230)
provided by on December 18, 2019 to March 17, 2020.
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care rendered on December 9, 2019.
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 routine foot care is not covered.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
The submitted records do not show that any of these conditions are present. The file shows that you received
callus and nail debridement with no sign of infection. The services you are asking the Plan to pay for are
routine foot care services. 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 pay for the routine foot care
rendered on December 9, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not
tried and failed bisphosphonates, and does not have a high risk of fracture.
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 Prolia. Our physician reviewer found
that the enrollee has osteoporosis. A DEXA scan is showing osteopenia. The Plan requires a trial of
bisphosphonates, and a history of fracture before they will approve the requested drug. In this case, the enrollee
has not tried and failed bisphosphonates. There is no documentation provided indicating that the Plan's required
drug would likely be less effective, or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening laboratory testing provided on January 27, 2020.
You asked the Plan to pay for screening tests. You say that your primary care provider referred you for this
testing in the same office location. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because these tests are not covered for screening purposes.
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 test at issue in this appeal, screening tests, was 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
screening laboratory testing provided on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Myocardial Perfusion imaging (78452)
provided February 25, 2020.
You asked the Plan to waive the copayment for the Myocardial Perfusion imaging. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct cost sharing 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 Nuclear Medicine Tests.
You have been asked to pay a $100 copayment for the Myocardial Perfusion imaging. The Myocardial
Perfusion imaging falls within the Nuclear Medicine Tests 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 Myocardial Perfusion imaging (78452) provided February 25, 2020.