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

 
We decided that the Plan does not have to pay the remaining amount for the scaling and root planing (D4342 x 
4), the unspecified preventive service (D1999), the localized delivery of antimicrobial agent (D4381 x 7), the 
topical application of fluoride (D1208), the Fluorodex (D0032), and the chlorhexidine rinse provided on 
September 1, 2020. 
 
You asked the Plan to pay the remaining amount for the dental services. You say that you went for a cleaning 
but were denied. You say that the dentist advised you needed a dental scanning prior to the cleaning. You say 
that you paid $685 upfront for the services. You say that you feel you are being scammed by the provider. You 
also say that you should be reimbursed for the over-payment. The Plan denied your request. The Plan says 
scaling and root planing is covered with a 50% coinsurance. The Plan says that the remaining services that you 
received are not covered. The Plan says that based on the treatment plan and your proof of payment, your 
payment was processed correctly. 
 
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 50% coinsurance for the 
scaling and root planing. The additional services that you received are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay the remaining amount for the scaling and root 
planing (D4342 x 4), the unspecified preventive service (D1999), the localized delivery of antimicrobial agent 
(D4381 x 7), the topical application of fluoride (D1208), the Fluorodex (D0032), and the chlorhexidine rinse 
provided on September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the vascular ultrasound on August 4, 2020. 
 
You asked the Plan to reduce the copayment for the vascular ultrasound. You say that this was a simple 
procedure that was completed. You say this was an outpatient diagnostic test and there should be a $7 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiological center or medical clinic).  
 
You have been asked to pay a $112.64 copayment, which is less than the standard copayment amount, for the 
vascular ultrasound. The vascular ultrasound falls within the 'Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies' benefit category. The record shows the vascular ultrasound is considered a radiological 
diagnostic procedure. 
 
  
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 reduce the copayment for the vascular ultrasound provided on August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you should not have a 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $285 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $285 copayment for the colonoscopy. The colonoscopy falls within the 
?Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
center? benefit category.  The record shows a diagnosis code for benign neoplasms of the colon which makes 
the colonoscopy diagnostic in nature. 
  
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 colonoscopy provided on August 13, 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 a CardioMEMS device. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has a diagnosis of Unspecified diastolic (congestive) heart failure. The
efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is
needed to determine the efficacy and safety of this device. Therefore, the enrollee does not meet criteria for the
requested 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a CardioMEMS device
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on December 23, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120), the bitewing x-rays (D0274), 
the periapical x-ray (D0220), and the periodontal maintenance (D4910) provided on July 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that according to the 2020 Annual Notice of 
Changes you can go to any dentist now. You say that it also states that if the out of network provider charges 
more than your plan then you would have to pay the difference. You say that the plan did not even pay the full 
amount. You also say that the plan should pay the difference. The Plan denied your request. The Plan says the 
provider in this case is out of network. The Plan says that dental services that you receive out of network are 
subject to a higher cost share. The Plan also says 
 
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, dental services that you receive out of 
network are subject to a higher cost share. You may be billed more by an out of network provider if the charge 
is greater than MAC. Cost sharing is a contractual obligation under the plan and cannot be waived. Therefore, 
we decided that the Plan does not have to pay for the oral evaluation (D0120), the bitewing x-rays (D0274), the 
periapical x-ray (D0220), and the periodontal maintenance (D4910) provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services with dental codes D0220, D0140, D2954, D3347, and D2740 provided on April 16, 2020 and April 27, 2020.

You asked the Plan to pay additionally for dental codes D0220, D0140, D2954, D3347, and D2740. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the dental claims processed correctly.

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.

We looked at the file, the Plan's contract and Medicare rules. The file shows the provider billed service D0220 in the amount of $31. The allowed amount for the service is $10. The Plan pays 100% of the allowable amount per the benefits outlined in the Evidence of Coverage. The Plan paid $10. You are responsible for all fees billed by the provider in excess of the allowed amount $21 ($31-$10). Your liability for dental code D0220 is $21.

The file shows the provider billed service D0140 in the amount of $70. The allowed amount for the service is $31. The Plan pays 100% of the allowable amount per the benefits outlined in the Evidence of Coverage. The Plan paid $31 and you are responsible for all fees billed by the provider in excess of the allowed amount $39 ($70-$31). Your liability for dental code D0140 is $31.

The file shows the provider billed service D2954 in the amount of $325. The allowed amount for the service is $128. The Plan pays 50% of the allowable amount per the benefits outlined in the Evidence of Coverage. The Plan paid $64 ($128 x 50%). You are responsible for a 50% coinsurance for this service $64 ($128 x 50%). You are also responsible for all fees billed by the provider in excess of the allowed amount $197 ($325-$128). Your liability for dental code D2954 is $261 ($64+$197).

The file shows the provider billed service D2740 in the amount of $995. The allowed amount for the service is $491. The Plan pays 50% of the allowable amount per the benefits outlined in the Evidence of Coverage. The Plan paid $245.50 ($491 x 50%). You are responsible for a 50% coinsurance for this service $245.50 ($491 x 50%). You are also responsible for all fees billed by the provider in excess of the allowed amount $504 ($995-$491). Your liability for dental code D2740 is $749.50 ($245.50+$504).

Though the Plan offers a dental benefit beyond Medicare coverage, dental code D3347 is not listed as a covered service. Therefore, we decided that the Plan does not have to pay additionally for the dental services with dental codes D0220, D0140, D2954, D3347, and D2740 provided on April 16, 2020 and April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microdissection (ie, sample preparation of 
microscopically identified target); manual (CPT Code 88381) and oncology (prostate), mRNA, microarray 
gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as metastasis risk score (81542) provided on June 25, 2020. 
 
You asked the Plan to pre-approve the testing. You say that you were told that the test would be covered and 
you would not be liable for any amount. The Plan denied your request. The Plan says based on the medical 
records provided there is no supporting documentation that the Medicare LCD criteria is met. The Plan states 
that it was noted that the vendor's notes did not have a referring physician signature on requisition form or 
order for the test to support medical necessity. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the documentation provided, the health plans denial should be upheld. You have 
already been diagnosed with high-risk prostate cancer, for which surgery was performed. Additional therapy, 
including radiation and hormone regulation, was recommended. There is no evidence to support that the 
requested genetic testing would affect your diagnosis or treatment plan. As such, the requested testing is not 
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 microdissection (ie, sample preparation of microscopically identified target); manual (CPT 
Code 88381) and oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, 
utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542) provided 
on June 25, 2020.
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 records provided support the need for 
care in an LTACH The Plan denied your request. The Plan says the services the enrollee is receiving in the 
acute inpatient level of care facility are the same that would be received at an LTACH. 
 
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 the enrollee was admitted to the current acute care hospital with COVID-19 
pneumonia and respiratory failure requiring mechanical ventilation, steroids, remdesivir, and convalescent 
plasma. She was also diagnosed with acute kidney injury and sepsis which were treated. She underwent 
tracheostomy placement and feeding tube placement. She was able wean off ventilation support and was able to 
decannulate. Based on the notes, the enrollee appears to be more stable and improving but requires only a short 
extension of acute care services which can be safely administered at the current facility. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
current facility that the enrollee requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to 
a lower level of care may be considered when treatment has completed. 
 
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: 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee is 
currently undergoing treatment at an acute care hospital (ACH), having been admitted with CKF and renal 
compromise. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services 
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has NYHA Class III 
congestive heart failure with preserved left ventricular ejection fraction (LVEF 55 to 60 percent) requiring 
hospital admission. 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. The efficacy of the CardioMEMs is uncertain and not the standard of care. The 
services are not 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 CardioMEMs HF System.
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 records provided support the need for 
care in an LTACH. The Plan denied your request. The Plan says the records show the enrollee is not medically 
stable. The Plan says that the enrollee needs to stay in the hospital until he is better. 
 
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 the enrollee was admitted to the current acute care hospital with respiratory failure 
and tension pneumothorax. The course was complicated by aspiration pneumonia and sepsis requiring 
antibiotics. Recent notes describe the enrollee continuing to require mechanical ventilation and treatment for 
unstable kidney function and fluid management. He has not yet undergone tracheostomy or PEG placement. He 
is still requiring sedation. Based on the notes, the enrollee appears to still be unstable, requiring additional 
acute care services which can be safely administered at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. There are no services at the current 
facility that the enrollee requires that are not already available and covered at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower 
level of care may be considered when the enrollee is more stable and when treatment has completed. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra (J0517).
You asked the Plan to pre-approve Fasenra. You say that this is medically necessary. The Plan denied your
request. The Plan says this is the responsibility of the enrollee's Part D prescription drug plan.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Fasenra (J0517).
Benefits for Fasenra 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit (CPT 99213) you had on July 2, 2020. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says payment is included in the 
payment for the surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for visits on the day of surgery for 
minor procedures is included in the Medicare approved amount for the procedure.  
 
We looked at the file and Medicare rules. Payment for visit (CPT 99213) on the day of the procedure (CPT 
11102) is included in the payment for the procedure. Separate payment cannot be made for the visit. Based on 
this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the visit (CPT 99213) you had on July 2, 2020.