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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the hospital needs to open beds. The Plan 
denied your request. The Plan says receiving appropriate care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found While you appear to be stabilizing, you require additional short term acute care 
services for further stabilization that can safely be completed in the current facility. You do not require services 
in the LTACH that are not already available at the current facility. Therefore, this request for LTACH services 
is considered not medically necessary at this time. Transfer may be considered when the treatment has 
completed and you are stable and appropriate for a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ambulance services (A0425, A0427) 
provided on May 18, 2020. 
 
You asked the Plan to waive the deductible for the ambulance services. You say that you are unhappy with the 
services provided. The Plan denied your request. The Plan says the deductible applied correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for ambulance services.  
 
You received ambulance services on May 18, 2020. The record shows that you had paid $0 toward the $750 
deductible prior to receiving the services. Therefore, you are responsible for the allowed amount of $437.37. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category ambulance 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the 
time the ambulance services was received on May 18, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for the ambulance services (A0425, A0427) provided on May 18, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a Supartz injection (J7321) and specialist 
office services (20610) received on July 28, 2020. 
 
You asked the Plan to waive the cost-sharing for a Supartz injection and specialist office services. You say that 
you believe the copayment has been waived for these services. The Plan denied your request. The Plan says 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 $35 
copayment for each visit to a specialist and 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $35 copayment for specialist office services. Specialist office services fall within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. You have also been 
asked to pay $15.15, or 20% of the Plan-allowed amount of $75.73, for a Supartz injection. A Supartz injection 
falls within the "Medicare Part B prescription drugs" 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 
cost-sharing for a Supartz injection (J7321) and specialist office services (20610) received on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Primidone. 
 
You asked the Plan to pre-approve Primidone. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare Part B. 
 
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 Primidone.  
 
Benefits for Primidone 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 6 extractions and 2 alveoplasty to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you were advised to see an oral surgeon to 
have a bone graft due to deterioration of the bone in your mouth and jaw. You say that you need to have these 
teeth extracted because you are in pain all of the time and cannot eat. The Plan denied your request. The Plan 
says dental services must be provided by a participating general dentist. The Plan also says dental services that 
you get from an oral surgeon are 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 services are not among 
those covered under this benefit if you receive them from an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve 6 extractions and 2 alveoplasty to be provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory tests provided on February 13, 2020.You asked the Plan to waive the copayment forthe laboratory tests. You say that you are being double charged for seeing your primary care doctor.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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for the laboratory tests. Laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefitcategory. 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 forlaboratory tests provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator and portable gaseous oxygen 
provided on June 28, 2020. 
 
You asked the Plan to pay for the oxygen concentrator and portable gaseous oxygen. The Plan denied your 
request. The Plan says in most cases care you receive from an out-of-network provider will not be covered. If 
you need medical care that Medicare requires our plan to cover and the providers in our network cannot 
provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain 
authorization from the plan prior to seeking care. 
 
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 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for an oxygen concentrator and portable gaseous oxygen provided on June 
28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 13, 2020, to January 14, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not 
transferred to a room and only stayed at the hospital one night. You feel that you should only owe an 
emergency room copayment and not an inpatient 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 $492 
copayment for inpatient hospital care.  
 
The medical records show that you received inpatient hospital care from January 13, 2020, to January 14, 2020. 
Therefore, you are responsible to pay the $492 copayment.  
 
You have been asked to pay a $492 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
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 
an inpatient hospital stay provided from January 13, 2020, to January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humalog KwikPen. 
 
You asked the Plan to pre-approve Humalog. You say that the enrollee is doing very well on this medication. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under 
Medicare Part B. 
 
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 a Humalog KwikPen.  
 
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 core build up (D2950) for teeth # 7, 8, 9, and 29. 
 
You asked the Plan to pre-approve the dental services. You say that tooth # 7 needs a crown. You say that there 
is an existing crown on tooth # 7 with visible open margins on all sides. The Plan denied your request. The Plan 
says core build up is not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for teeth # 7, 8, 9, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental items. You say that you need this procedure. You say that you are 
20 to 25 pounds underweight. You say that you are on a feeding tube. You also say that you are unable to chew 
food and had cancer surgery. The Plan denied your request. The Plan says the requested dental implants are 
dental in nature. The Plan also says that dental implants 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental implants are not 
among those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve 
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. Therefore, we decided that 
the Plan does not have to pre-approve dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame with accessories (E0637, E0978, 
K0108). 
 
You asked the Plan to pre-approve the standing frame and accessories. You say that the standing frame is 
medically necessary. The Plan denied your request. The Plan says standing frames are considered a 
convenience item and are not covered. 
 
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 a standing frame with accessories (E0637, E0978, K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 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 are not covered. 
 
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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a WalkAide Functional Electrical Stimulation (FES) 
system. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a spinal cord injury. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NMES is covered when specific criteria are met. 
 
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 a history of cervical 
spinal stenosis with left upper extremity and left lower extremity weakness and difficulty walking. She does not 
have a qualifying spinal cord injury, as required by the Medicare criteria. There is no documentation to support 
that the requested FES is reasonable or 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 WalkAide Functional Electrical Stimulation (FES) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core in addition to a crown 
(D2954). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown is not 
listed as a covered service. The Plan also says any services no listed are 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. The Customer Handbook specifically says 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 prefabricated post and core in addition to a crown (D2954).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
physician. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested physician. You say that 
the enrollee was misdiagnosed by the in-network physician and then she saw the physician at issue in this case 
and was diagnosed correctly as having Corticobasal syndrome and not Parkinson's disease. You say that this 
physician has a better understanding her condition. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft (D7953). 
 
You asked the Plan to pre-approve the bone replacement graft (D7953). You say that you received the denial 
for the bone graft and want to file an appeal. 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 
bone replacement graft (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic analysis of cochlear implant (96204) provided to 
the enrollee on June 23, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered for the enrollee. The 
Plan denied your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of services as stated 
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 pay for this service. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found the guidelines under Medicare for 
cochlear implants states that the enrollee must have moderate-to-profound hearing loss. They must also have 
limited benefit from amplification is defined by test scores of less than or equal to 40% correct in the best-aided 
listening condition on tape-recorded tests of open-set sentence cognition. This audiogram from 2017 does not 
show a moderate to profound loss, but rather a moderate to severe loss. Therefore, he does not meet the 
required criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the 
Plan does not have to pay for diagnostic analysis of cochlear implant (96204) provided to the enrollee on June 
23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the 5 extractions provided on June 11, 2020. 
 
You asked the Plan to reimburse more for the dental services. You say that you had a root canal. You say that 
your nerve cracked and you got an infection. You say that you were advised you needed the tooth to be 
removed. You say that a plan representative advised that you had dental coverage and that you needed to pay 
up front and would be reimbursed. You also say that you had to borrow money from your son to pay for these 
services. The Plan denied your request. The Plan says there is a maximum allowance of $525 for preventive 
and comprehensive dental services. The Plan also says that the maximum allowance has been exhausted. 
 
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 maximum allowance of $525 for 
dental services has been exhausted. The record shows that the plan paid $525 towards the interim partial 
denture that you received on this date of service, thus exhausting the maximum allowance. Therefore, we 
decided that the Plan does not have to reimburse more for the 5 extractions provided on June 11, 2020.