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

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you feel you were treated unfairly. You say 
that it is not your fault that the dentist was not in the office at the time. You also say that you have not been 
able to chew your food because you only have 2 front teeth left. The Plan denied your request. The Plan says 
partial dentures are covered once every 60 months. The Plan also says the frequency limit of once every 60 
months 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 60 months has been reached. The record shows that you received a partial upper 
denture on January 16, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper 
denture (D5213).  
 
Your complaint about being treated unfairly 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) and therapeutic activities 
(97530) provided on February 8, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises and activities. You say that you disagree with the denial. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network providers. 
 
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 therapeutic exercises (97110) and therapeutic 
activities (97530) provided on February 8, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 5, 2020 through 
January 22, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the 
member did not meet coverage criteria for the inpatient admission. 
 
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 records show that at the time of inpatient admission the admitting physician reasonably 
expected that the patient'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 January 5, 2020 through January 22, 2020.  
 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to go home without severe risk 
of further complications. The Plan denied your request. The Plan says that no skilled therapies or nursing care 
needs are identified. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brow ptosis repair (67900). 
 
You asked the Plan to pre-approve brow ptosis repair. You say that blepharoplasty alone will not be sufficient. 
The Plan denied your request. The Plan says here is not evidence the enrollee's vision would improve with this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that brow ptosis repair is necessary in some cases to 
provide an adequate functional result when the requirements listed above 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 brow ptosis repair.  
 
 
Our reviewer says that the criteria for coverage of brow ptosis repair have not been met. Our physician 
reviewer found the documentation is not sufficient to demonstrate that the requested brow ptosis repair is 
medically necessary to provide an adequate functional result. The file does not include frontal photographs 
demonstrating drooping of brows below the superior orbital rim; and improvement of blepharoptosis or 
dermatochalasis by elevation of the brows. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brow ptosis repair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve brow ptosis repair (67900).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 11, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Botox injection (64612) provided May 20, 
2020. 
 
You asked the Plan to waive the copayment for the Botox injection. You say that you receive this treatment 
every 3 months due to a medical condition to your face. You were told your copay would be $40. You can pay 
$40 but $100 is too expensive for you. The Plan denied your request. The Plan says the correct copayment has 
been applied per the plan benefits. 
 
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 for Medicare covered surgery or other services at an outpatient hospital or ambulatory surgical 
center.  
 
You have been asked to pay $100 copayment for the Botox injection. The Botox injection falls within the 
Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 Botox injection (64612) 
provided May 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay at a SNF from October 8 to 
November 13, 2019. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that you are disputing this charge due 
to the quality of care provided. 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 
$167.50 copayment for each day of days 21-100 of a stay at a SNF.  
 
You have been asked to pay $1,954, a less than a $167.50 copayment for 16 days of a stay at a SNF. A stay at a 
SNF falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been 
asked to pay less than the full 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 stay at a SNF from October 8 to November 13, 2019.  
 
We read your letter and knows that you may have a quality of care concern. We 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and extraction. You say that due to the nature of the tooth, 
you need to have the tooth extracted by an oral surgeon. The Plan denied your request. The Plan says dental 
services performed by 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 items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a mental health counselor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a licensed mental health counselor is not eligible to 
participate in Medicare. 
 
We looked at the file and Medicare rules. The requested provider is a licensed mental health counselor. This 
provider type is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
referral to a mental health counselor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection, anesthetic agent and/or steroid; nerves 
innervating the sacroiliac joint, with image guidance (64451). 
 
You asked the Plan to pre-approve the sacroiliac joint procedure. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is 
considered experimental or investigational and not proven to be helpful. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sacroiliac joint procedure have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection, anesthetic agent and/or steroid; nerves innervating the sacroiliac joint, with image 
guidance (64451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 28, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 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 out of network physician 
services provided to the enrollee on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the office visit. The Plan denied your request. The Plan says the service is 
available within the network and member?s condition is not an emergency. 
 
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 an office 
visit to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care provider office visit (99214) 
on June 25, 2020. 
 
You asked the Plan to waive the copayment for a primary care provider office visit. You say that this service 
was your annual wellness visit and so should be fully covered. 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 $10 
copayment for each primary care doctor visit for Medicare-covered benefits.  
 
You have been asked to pay a $10 copayment for a primary care provider office visit. The case record indicates 
you visited the office for evaluation of symptoms. The services you received during this visit do not fall within 
the category of an annual wellness visit. A primary care provider office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" 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 a primary care provider office visit (99214) on June 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and therapeutic activities 
(97530) provided on March 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises and activities. You say that you disagree with the denial. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network providers. 
 
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 therapeutic exercises (97110) and therapeutic 
activities (97530) provided on March 14, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 28, 2020. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are disputing this 
copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct. 
 
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 $225 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay $225 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services 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 ambulance 
transportation provided on March 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on December 19, 2019.You asked the Planto waive the copayment for an injection. You say that all you had was an injection at the doctor's office. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery. You have been asked to pay $234.98 which is less than your copayment amount of $275 for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery benefit category. This means that youhave 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 injection provided by a participating provider on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right sided cervical radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that in order to move forward with 
radiofrequency denervation to medial branch blocks are required in order to perform radiofrequency 
denervation. If someone has bilateral symptoms, they need to have 6 procedures total. The Plan denied your 
request. The Plan says records show that you have had 5 sessions. This request exceeds the maximum of 
number of injections allowed for this period of time. 
 
The Plan must follow Medicare rules. Medicare covers a maximum of 5 facet joint injection sessions inclusive 
of medial branch blocks, intra-articular injections, facet cyst rupture and RF ablations may be performed per 
year. The records show that you have received the maximum of the 5 injection sessions. Based on this 
information, we decided that Medicare rules for coverage of the radiofrequency ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve right sided cervical radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (9937) provided on June 1, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary home visit. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-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 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 domiciliary or rest home visit (9937) provided 
on June 1, 2020, by an out of network (OON) provider.