Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider from August 25, 2020, to August 26, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were kept for 
observation, not as an inpatient. 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 $310 
copayment per day for days 1-7. There is a $0 copayment for additional days. for inpatient hospital care/in-
network.  
 
You have been asked to pay a $310 copayment for one day for an inpatient hospital stay. An inpatient hospital 
stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider from August 25, 2020, to August 
26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccination provided on August 21, 2020. 
 
You asked the Plan to pay for the tetanus vaccination. You say that the tetanus vaccination was necessary for 
protection. The Plan denied your request. The Plan says routine tetanus vaccinations are not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus 
vaccination. The Plan follows the same rules.  
 
Records do not show that the enrollee has been injured or directly exposed to any illness related to the tetanus 
vaccination. Therefore, we decided that the Plan does not have to pay for the tetanus vaccination provided on 
August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from April 11, 2020, to April 12, 
2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the inpatient care. Our reviewer says that 
that the inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee had cardiac arrest prior to arrival to the ED and was resuscitated and was intubated. He was placed on 
vasopressors and was admitted to the ICU. By April 11, 2020, the enrollee was designated as "DNR", was 
awake and alert and was extubated and off vasopressors according to the notes. He required low flow oxygen 
and vitals were stable. The enrollee was stable and appropriate for transfer on April 11, 2020, at 2:07 pm. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from April 11, 2020, to April 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist consultation to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist consultation. You say that you would like approval for this out-of-network physician.The Plan denied your request. The Plan says these services can be provided in-network.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-approvea specialist consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on September 21, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for physician/practitioner services/in-network/provider services/specialist/s office.  
 
You have been asked to pay a $50 copayment for specialist services. These services were not denied. The 
correct copayment has been applied to the services that were provided. Specialist services fall within the 
physician/practitioner services/in-network/provider services/specialist/s office 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 specialist services provided by a participating provider on September 
21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on October 31, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that this telehealth visit 
was not with a specialist. 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for specialist telehealth services. A nurse practitioner is 
considered a specialist; therefore, the correct copayment has been applied. Specialist telehealth services falls 
within the physician/practitioner services/specialist 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 specialist telehealth services provided by a participating provider on October 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided to the enrollee on July 28, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the dental 
services provided to the enrollee on July 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on January 30, 
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 the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 3, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on January 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on March 3, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
services at issue. 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 nurse practitioner services provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on June 4, 2020. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that $45 is too much to pay for 
just clipping nails. The Plan denied your request. The Plan says the provider billed for podiatry office visit 
services not just nail clipping. 
 
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 Podiatry services.  
 
You have been asked to pay a $45 copayment for the podiatry services. The podiatry services fall within the 
Podiatry Services benefit category. The medical record shows office visit services were rendered. 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 podiatry services provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and prefabricated post and core in 
addition to crown (D2954) provided on October 15, 2020. 
 
You asked the Plan to pay for the crown and prefabricated post and core. You say that you were told that even 
though you used your available benefits of $1000.00 your dental work would be paid for because you had prior 
authorization, and the work was medically necessary. The Plan denied your request. The Plan says you have 
maxed out your allowable benefit for the year. 
 
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 $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on October 15, 2020 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the crown (D2750) and prefabricated post and core in addition to 
crown (D2954) provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that you were not satisfied with your previous dentures and returned them. You also say that the office never 
reimbursed the Plan for the dentures. The Plan denied your request. The Plan says these services exceed the 
maximum count allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
July 21, 2020, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and 
abutment supported porcelain/ceramic crown. 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported 
porcelain/ceramic crown. You say that you need the dental implant as soon as possible. The Plan denied your 
request. The Plan says these services are not covered under your 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 pre-approve an 
endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulsed electromagnetic field therapy mat. 
 
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 the services are experimental/investigational in nature. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has lumbar degenerative 
disc disease, cervical spine arthritis, chronic pain syndrome, and fibromyalgia. She wants to discontinue her 
muscle relaxers as they make her tired and she notes her Meloxicam is not working as well as it used to. She is 
interested in a pulsed electromagnetic field mat to help with her chronic pain through Swiss Bionic Solutions. 
Based on existing evidence, the requested services are considered experimental/investigational in nature and 
are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pulsed electromagnetic field therapy mat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth #10. 
 
You asked the Plan to pre-approve the endosteal implant. You say that you would like to appeal the denial of 
this service. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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. The Plan covers the endosteal 
implant when the services are medically necessary and reasonable.  
 
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 endosteal implant. Our reviewer 
says that the criteria of "medically reasonable" for placement of an implant (D6010) have not been met. Our 
physician reviewer found your dental record and radiographs indicate the presence of a large radiolucent area 
associated with tooth #10, indicating a periapical infection and loss of bone. Our reviewer also found that an 
implant is contraindicated at this time, due to the lack of healthy bone where the implant would be placed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the endosteal implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an endosteal implant (D6010) for tooth #10.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
 
 
 
 
 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction provided on October 8, 2020. 
 
You asked the Plan to pay for the surgical extraction. You say that you feel that this should be covered under 
your insurance because it was a medical issue. The Plan denied your request. The Plan says this service is not 
covered under your routine dental services, nor was it completed to prepare the jaw for radiation treatment of 
neoplastic cancer disease. 
 
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. This service is dental in nature. Therefore, we decided that the Plan 
does not have to pay for the surgical extraction provided on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aloxi. 
 
You asked the Plan to pre-approve Aloxi. You say that the medication is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aloxi. Our reviewer says that Aloxi is 
not medically necessary. Our physician reviewer found the use of palonsetron (Aloxi) is for the prevention of 
acute and delayed nausea and vomiting associated with initial and repeat courses in adults treated with 
moderately or highly emetogenic chemotherapy. Mitomycin and flurouracil are low emetogenic potential 
chemotherapies and Aloxi woud not be inidicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Aloxi.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whole exome sequencing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient evidence to support the clinical utility for genetic testing for autism 
spectrum disorder. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has autism and developmental delay. Prior extensive genetic testing has been non-
diagnostic. Panel testing, inclusive of testing that is not related to a specific sign or symptom, or for which 
there are no associated therapies, is not medically necessary or reasonable. The documentation does not support 
that the requested genetic panel testing is medically necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve whole exome sequencing for the enrollee.