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

 
We decided that the Plan does not have to pay for the federally qualified health center (FQHC) encounter 
payment (T1015) and the lower partial denture (D5214) provided on December 31, 2019 by the out of network 
dental provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says hospital or other 
facility charges are excluded from coverage. The Plan says that the provider in this case is not a network 
provider. The Plan also says services received out of network 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, hospital or other facility charges are 
excluded from coverage. Additionally, services performed by an out of network dentist if your plan does not 
have out of network coverage are not covered. Therefore, we decided that the Plan does not have to pay for the 
federally qualified health center (FQHC) encounter payment (T1015) and the lower partial denture (D5214) 
provided on December 31, 2019 by the out of network dental provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99203) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you do not wish 
to return to the in-network provider previously seen. The Plan denied your request. The Plan says there are 
multiple in-network specialists available that can provide the service at issue. 
 
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-approve 
the new patient office or other outpatient visit (99203) 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 radiation therapy management (77263) 
received on May 20, 2020. 
 
You asked the Plan to waive the copayment for radiation therapy management. You say that this copayment 
should be waived as part of the Plan's initiative related to the COVID-19 pandemic. The Plan denied your 
request. The Plan says the correct copayment 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
You have been asked to pay a $60 copayment for radiation therapy management. Radiation therapy 
management 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 radiation therapy management (77263) 
received on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and electrical connection. 
 
You asked the Plan to pre-approve power seat elevation feature and electrical connection. You say that the 
enrollee is unable to use a mechanical switch and will only be able to use the wheelchair features with these 
key components. The Plan denied your request. The Plan says the denial of authorization for these devices is 
correct, because these power wheelchair features are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that a power seat elevation is not covered by Medicare, and an 
electrical connection is also non-covered if its sole purpose is for a power seat elevation feature. 
 
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 power seat elevation feature and 
electrical connection. Our reviewer says that the requested electrical connection is not considered medically 
reasonable or necessary in this case. Our physician reviewer found there is no documentation that the purpose 
of this electrical connection is to power other features of the wheelchair besides the seat elevation feature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seat elevation feature and electrical connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and electrical 
connection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the services 
were provided by a non-participating facility. The Plan also says that the services were not referred by a 
network provider. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 26, 2020 
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan provided on May 11, 2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you don't recall having this test 
done and didn't agree to have it done. You say that you don't agree with the $25 copayment. 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 $25 
copayment for a Medicare-covered ultrasound.  
 
You have been asked to pay a $25 copayment for the duplex scan. The duplex scan falls within the "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The records show that the duplex 
scan was performed. 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 duplex scan provided on 
May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are not able to stand alone and struggle in 
the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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. 
 
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 this device has deluxe features that exceed your need and 
replaces, rather than improves the arm function. 
 
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 powered upper 
extremity range of motion assist device (L8702) 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on May 7, 
2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel. 
 
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 was requested for screening purposes. The medical records provided do not 
show that the testing was provided to determine a specific treatment strategy or diagnosis. Medicare does not 
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cardiovascular testing provided on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs and medicaments (D9630 x 4). 
 
You asked the Plan to pre-approve the drugs and medicaments. The Plan denied your request. The Plan says 
drugs and medicaments are not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
drugs and medicaments (D9630 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on January 21, 2020 by 
an OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that the services were medically necessary 
due to the enrollee's condition. The Plan denied your request. The Plan says the service was rendered by a non-
participating provider. The Plan also says that prior authorization was not obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on January 21, 
2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer assistance for instrumentation placement a 
during spinal fusion. 
 
You asked the Plan to pre-approve the requested services. You say that the service is needed for 
instrumentation placement for the posterior spinal fusion. The Plan denied your request. The Plan says the 
service is not medically necessary for the enrollee's procedure. 
 
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 requested services. Our physician 
reviewer found that the requested navigation remains experimental in cases of spinal fusion surgery. More 
research is needed to show safety and efficacy. It is not the standard of care for lumbar fusion surgery. 
Therefore, the requested services are not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computer assistance for instrumentation placement a during spinal fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing for all 4 
quadrants (D4341). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says periodontal 
scaling and root planing is covered once every 36 months. The Plan says that the frequency limit has been 
reached. 
 
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 and the requested service is listed as 
covered, coverage is limited to once every 36 months. The record shows that you received periodontal scaling 
and root planing for the upper and lower right quadrants on March 26, 2019 and the upper and lower left 
quadrants on April 6, 2019. Therefore, we decided that the Plan does not have to pre-approve the periodontal 
scaling and root planing for all 4 quadrants (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
25, 2020. 
 
You asked the Plan to pay for the dental services. You say that you moved in March 2020. You say that you 
were establishing care with your current dentist. You say that no dentist is going to do any work without an 
evaluation. You also say that it is ridiculous that this service is only covered once every 36 months. The Plan 
denied your request. The Plan says comprehensive oral evaluations are covered once every 3 plan years. The 
Plan says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is 
listed as covered, the frequency limit has been exceeded. The record shows that you received this service on 
February 20, 2018. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) provided on June 25, 2020.  
 
Your complaint about the coverage for this service 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you are unable to perform activities of daily 
living without assistance and require SNF care. The Plan denied your request. The Plan says the denial of 
authorization for SNF service is correct. 
 
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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
Skilled Nursing Facility (SNF) 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x 2) and an 
abutment supported retainer (D6069). 
 
You asked the Plan to pre-approve the dental services. You say that the services were previously approved in 
2019. You say that the enrollee needs these services to restore the aesthetics of their dentition and properly 
functioning bite. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a 
covered service. The Plan says abutment supported retainer is not listed as a covered service. The Plan also 
says any services not 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 and the services were previously 
approved, the requested services are no longer among those covered under the 2020 Dental benefit. Therefore, 
we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x 2) and an 
abutment supported retainer (D6069).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe wound pump you received from March 30, 2020, to April 29, 2020.You asked the Plan to waive the coinsurance forthe wound pump. You say that you shouldn't have to pay this coinsurance since the wound pump was needed because the doctor didn't perform surgery correctly.The Plan denied your request. The Plan says you were charged this coinsurancecorrectly.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 20% coinsurance for durable medical equipment that costs more than $100. You have been asked to pay 20% coinsurance for the wound pump. The wound pump falls within the durable medical equipment that costs more than $100 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 coinsurance forthe wound pump you received from March 30, 2020, to April 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and the bitewing x-rays (D0274) provided on December 19, 2019 by the non-participating dental provider. 
 
You asked the Plan to pay for the dental services. You say that the services were provided by your assigned 
dentist. The Plan denied your request. The Plan says the provider in this case is not a participating dentist. The 
Plan says that services you receive from a non-participating dentist 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services you receive from a non-
participating dentist is not covered. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on December 19, 
2019 by the non-participating dental provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid first. 
 
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 reviewer says that the Plan's 
step therapy criteria has not been met. Our physician reviewer found the enrollee is with postmenopausal 
osteoporosis without current pathologic fracture. She has failed treatment with oral risedronate and alendronate. 
Prolia injections have been requested. The health plan denied coverage for the Prolia as the plan requires a trial 
of zoledronic acid before they will approve the requested drug, Prolia. 

Based on the medical records provided the enrollee has not tried and failed the required drug. There is no 
indication that the Plan's required drug would likely be less effective and/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.