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

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you returned the dentures to the dental office. 
You say that when you called the dental office, the lady you spoke to claimed to have no record of you 
returning the dentures. You also say that you had no reason to keep the dentures you received as they did not 
fit. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also 
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 dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that you received dentures on 
October 28, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on June 19, 
2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the request for the Guardant 360 panel and the medical records have been reviewed. The 
Plan says that on August 7, 2020 the FDA approved Guardant 360 testing only for NSCLC. The enrollee does 
not have NSCLC. Thus, testing does not meet the Medicare coverage requirements. In addition, a panel 
constitutes a single procedural service and must be billed under procedural service 81479. Therefore, based on 
the diagnosis and the claim billed, Medicare billing criteria are not met.  
 
 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. In this 
case, the claim is missing the main code and identifier required by Medicare and the enrollee does not have the 
diagnosis required for this testing. Medicare rules for coverage of this claim have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) provided 
on June 24, 2020. 
 
You asked the Plan to waive the copay for the MRI. You say that you never paid for an MRI in the past. The 
Plan denied your request. The Plan says the copay was applied appropriately. 
 
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 $300 
copay for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $300 copay for the MRI. The testing falls within the outpatient diagnostic tests 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copay for the magnetic resonance imaging 
(MRI) provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies for external drug infusion pump (A4222) 
provided February 26, 2020 to March 2, 2020. 
 
You asked the Plan to pay for the infusion supplies. You say that please review this information and reconsider 
for payment. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the billed supply or an itemized shipping/billing 
invoice to indicate the specific supplies for the supplies provided in this case. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for infusion supplies for external drug infusion pump (A4222) provided February 26, 
2020 to March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient psychiatric hospital care 
provided May 26, 2020 to June 1, 2020. 
 
You asked the Plan to waive the copayment for the inpatient psychiatric care. You say that you are appealing 
because of improper care and harm done to you during your stay. You left the center in no better shape because 
of the treatment you received. The Plan denied your request. The Plan says this claim was processed correctly 
and the correct copayment was applied per the Evidence of Coverage. 
 
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 $100 
copayment per day for days 1-4, $0 copayment per day for days 5-90 for inpatient mental health care.  
 
You have been asked to pay $400 for the inpatient psychiatric care. The inpatient psychiatric care falls within 
the Inpatient mental health 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 
the inpatient psychiatric hospital care provided May 26, 2020 to June 1, 2020.  
 
Your complaint about the care you received while inpatient in the facility 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two 
implant supported crowns (D6066 x2). 
 
You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say 
that these services are needed in order to complete the implant procedures. The Plan denied your request. The 
Plan says these services are not covered under the enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME), it stays 
roll on glue (E1399) and sales tax (S9999) purchased on February 7, 2020 from a non-Medicare certified 
provider. 
 
You asked the Plan to pay for the DME item and sales tax. You say that you understood that the Plan would 
reimburse you the cost to you after the procedure was completed. You verified this with the Plan. The Plan 
denied your request. The Plan says these items are non-covered items and the provider is not a Medicare 
enrolled provider and therefore is not eligible for reimbursement from Medicare. Code S9999 for sales tax is 
not payable as they are included in the cost of DME.   
 
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 rules say that for equipment to be covered, it must primarily 
serve a medical purpose.   
 
The provider in this case is not eligible to participate with Medicare. The items 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. 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 miscellaneous durable 
medical equipment (DME), it stays roll on glue (E1399) and sales tax (S9999) purchased on February 7, 2020 
from a non-Medicare certified provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the topical application of fluoride (D1208) and 
periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. You say 
that the enrollee need to come back at least a month from September 29, 2020 to bring gums back to a health 
state. The Plan denied your request. The Plan says topical application of fluoride is not listed as a covered 
service. The Plan also says that periodontal maintenance is not covered within 90 days of receiving scaling and 
root planing.  
 
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 topical application of fluoride is 
not among those covered under this benefit. Additionally, periodontal maintenance is not covered within 90 
days of receiving scaling and root planing. The record shows that you received scaling and root planing on 
September 29, 2020. Therefore, we decided that the Plan does not have to pre-approve the topical application 
of fluoride (D1208) and periodontal maintenance (D4910).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 8, 2019 to 
November 7, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services rendered were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was chronically ill hemodialysis and presented with acute respiratory failure. The 
enrollee clearly meets admission criteria and was critically ill. The inpatient admission provided was medically 
reasonable and necessary based on the documentation. The records show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 8, 2019 to November 7, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. You also say that 
you cannot eat because you do not have any teeth. The Plan denied your request. The Plan says removal of 
lateral exostosis 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, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of lateral exostosis 
(D7471 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis services provided on December 27, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the urinalysis services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an OON 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 has network providers 
available who can provide the items/services at issue in this appeal. 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 urinalysis services provided on December 27, 
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on June 15, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised by the dentist that fluoride was 
covered by your plan. You say that you did not request this service. You also say that you never received a bill 
from this dental office. The Plan denied your request. The Plan says the topical application of fluoride varnish 
is 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 pay for the 
topical application of fluoride varnish (D1206) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided by a 
participating hospital on February 13, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you don't understand 
why you are being told you owe more now. The Plan denied your request. The Plan says the correct 
coinsurance 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 20% 
coinsurance for outpatient hospital services/outpatient hospital visit.  
 
You have been asked to pay less than a 20% coinsurance of the allowed amount for outpatient hospital 
services. The total allowed amount is $2,665.22. The total coinsurance amount is $551.43 ($2,665.22 x 20% = 
$551.43). You are being asked to pay a total amount of $424.21. Outpatient hospital services falls within the 
outpatient hospital services/outpatient hospital visit 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 for outpatient hospital services provided by a participating hospital on February 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided on April 22, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $220 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $220 copayment for the one-way Medicare-covered ground ambulance trip 
provided. 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 ambulance transportation service (A0427) 
provided on April 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) 
performed on February 10, 2020. 
 
You asked the Plan to waive the copayment for a transvaginal ultrasound. You say that you were never before 
responsible for a copayment for an ultrasound. 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 $215 
copayment for covered diagnostic radiology services in the outpatient department of a network hospital or 
facility.  
 
You have been asked to pay a $100.51 copayment for a transvaginal ultrasound. A transvaginal ultrasound falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) performed on 
February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3330) and an unspecified endodontic 
service (D3999). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says there is not a valid referral on file for the requested services. The Plan says a 
referral to a specialist is required from your general dentist. The Plan also says unspecified endodontic service 
is 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 unspecified endodontic service is 
not among those covered under this benefit. Additionally, although root canal is listed as a covered service, 
there is no valid referral on file. Therefore, we decided that the Plan does not have to pre-approve a root canal 
(D3330) and an unspecified endodontic service (D3999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 12, 2020. 
 
You asked the Plan to pay for the physician's services. 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 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 
physician?s services. 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 physician's services provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided 
on April 16, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that all of the Plan's in-network dentists 
were closed. You also say that you cannot afford to pay $534 out of pocket. The Plan denied your request. The 
Plan says this 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 pay for the bone 
replacement graft for ridge preservation provided on April 16, 2020.