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

We decided that the Plan does not have to pay for the bitewings (D0274) provided on June 30, 2020. 
 
You asked the Plan to pay for the bitewings. You say that the dentist was told that this visit would be covered 
at a zero copay for preventive dental x-rays and an exam. The Plan denied your request. The Plan says this 
service is not covered by the Plan. 
 
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 
bitewings (D0274) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused exam (D0140) and the cone beam CT 
(D0366) provided on June 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered since the dentist 
is both a MD and DDS. You also say that the dentist is in network with the plan. The Plan denied your request. 
The Plan says the services you received are dental in nature. The Plan says that problem focused exam is not 
listed as a covered service. The Plan also says that cone beam CT 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 services that you received are 
dental in nature. Additionally, the services you received are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the problem focused exam (D0140) and the cone 
beam CT (D0366) provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, 
spine (72080) radiologic examination, spine, cervical (72040) provided March 16, 2020. 
 
You asked the Plan to pay for the office visit and x-rays. You say that you do not believe the reduction is 
justified. You request that the reductions be reversed and an additional payment be made. The Plan denied your 
request. The Plan says the claim processed correctly as these services are not covered when billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient 
office visit (99203) radiologic examination, spine (72080) radiologic examination, spine, cervical (72040) 
provided March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on January 23, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99213) provided on January 23, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with electrocardiogram (99214, 93000) 
provided on November 4, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with electrocardiogram. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 office visit with electrocardiogram (99214, 
93000) provided on November 4, 2019, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on January 
13, 2020, through February 11, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary and can be rendered in a home 
setting or at a doctor's office. 
 
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 pay for SNF. Our reviewer says that daily skilled 
services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. 
The beneficiary does not require skilled nursing or therapy services on a daily basis and this beneficiary does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for skilled nursing facility (SNF) services provided on January 13, 2020, through February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were mobile before bypass surgery. The Plan 
denied your request. The Plan says your need are not complex, and you do not require an intensive 
multidisciplinary team approach to restore function. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for chest pain, and had coronary bypass surgery. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home evaluation and management (EM) services 
provided on October 18, 2019 billed with code 99350. 
 
You asked the Plan to pay for the home EM services. You say that the services rendered were medically 
necessary and should be covered. The Plan denied your request. The Plan says the records do not support the 
billing of this code. 
 
The Plan must follow Medicare rules. Medicare rules say that home EM codes, such as 99350, cannot be billed 
unless the billing provider was physically present in the enrollee's home.  
 
In this case, the records show that the services were provided on this date by a Licensed Vocational Nurse. 
There is no evidence that the billing physician was physically present. Therefore, we decided that the Plan does 
not have to pay for the home evaluation and management (EM) services provided on October 18, 2019 billed 
with code 99350.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional $5,100 for hearing aids. 
 
You asked the Plan to pre-approve an additional $5,100 for hearing aids. The Plan denied your request. The 
Plan says that the Plan pays up to a $500 allowance for hearing aids every 3 years. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids up to a $500 allowance every 3 years. 
 
We looked at the file and the Plan's rules. The Plan's hearing aid benefit covers up to a $500 allowance every 3 
years. Therefore, we decided that the Plan does not have to pre-approve an additional $5,100 for hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from June 1, 2020, to June 
4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services provided from June 1, 2020, to June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not 
support that you can tolerate or requires 3 hours of daily intense therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for lumbar surgery after a fall. Your medical problems are stable. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 300mg of Entyvio every four weeks. 
 
You asked the Plan to pre-approve 300mg of Entyvio every four weeks. You say that this frequency is needed 
because your symptoms are returning between doses. The Plan denied your request. The Plan says this 
dosage/frequency is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 300mg of Entyvio every four weeks. 
Our reviewer says that the criteria for the requested dose of Entyvio have not been met. Our physician reviewer 
found the records show that you take vendolizumab every eight weeks to treat Crohn's disease. While you 
argue that your symptoms return four weeks prior to your next dose, a recent office note indicates that 
symptoms returned only one day before your next dose.  Therefore, the documentation does not support that an 
increase dosing frequency is currently 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 300mg of Entyvio every four weeks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 300mg of Entyvio every four weeks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from July 20, 2020, to July 24, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are on a fixed 
income and you cannot afford this copayment. The Plan denied your request. The Plan says you were charged 
this copayment 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 $275 
copayment per day for days 1-6 for inpatient care.  
 
You have been asked to pay a $275 copayment per day for the inpatient hospital services, for a total of $1100. 
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 hospital services you received from July 20, 
2020, to July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 fillings and the personal protective equipment (PPE) 
reimbursement provided on June 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited income. You say that you 
have an agreement with the plan. You also say that you feel that you are being discriminated against. The Plan 
denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also 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 fillings are listed as covered, the 
frequency limit of 2 every calendar year has been exceeded. The record shows that the Plan paid for 2 fillings 
that you received on May 11, 2020. Therefore, we decided that the Plan does not have to pay for the 3 fillings 
and the personal protective equipment (PPE) reimbursement provided on June 22, 2020.  
 
Your complaint about being discriminated against 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 a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee needs the denture. The Plan 
denied your request. The Plan says dentures are covered once every 60 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 dentures are a covered service, the 
frequency limit of once every 60 months has been reached. The record shows that you last received a complete 
upper denture on September 25, 2019. Additionally, the Customer Handbook says coverage is limited to the 
frequency limits in the chart. Any services provided that are over the frequency limit are not covered. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says a reason was not given 
for the drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing services provided on June 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care from April 30, 2020, 
through May 18, 2020. 
 
You asked the Plan to pay for SNF. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says the member did not require daily skilled services at an inpatient skilled 
nursing facility level of care. 
 
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 pay for SNF. Our reviewer says that daily skilled 
services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. 
The beneficiary does not require skilled nursing or therapy services on a daily basis and this beneficiary does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for skilled nursing facility (SNF) care from April 30, 2020, through May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 2, 2020. 
 
You asked the Plan to pay for dental services. You say that you should have been told at the time of your visit 
if they didn't take your insurance. You say that you would have went somewhere else if you had you known. 
The Plan denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on July 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided from June 26, 
2020, through July 8, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were informed you no 
longer had a copayment. You say that you would not have had therapy if you knew you had a $40 copayment 
each time. The Plan denied your request. The Plan says the copayments 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 $40 
copayment for Medicare-covered physical therapy and/or speech and language pathology visits. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is 
$200 ($40/visit x 5 visits = $200). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from June 26, 2020, 
through July 8, 2020.