Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis (74177) provided on September 23, 2020. 
 
You asked the Plan to waive the copayment for the CT scan of the abdomen and pelvis. You say that you 
would like this copayment waived. The Plan denied your request. The Plan says the copayment has processed 
correctly in this case. 
 
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 $295 
copayment for CT scans.  
 
You have been asked to pay a $295 copayment for the CT scan of the abdomen and pelvis. The service 
provided falls within the CT scans 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 computed tomography (CT) scan of the abdomen and pelvis (74177) provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a clinical Crown Lengthening - Hard Tissue (D4249). 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not covered under your benefit 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. Specifically, the service requested is not listed in the Plan's benefit 
chart. This means the service is not covered under your benefit Plan. Therefore, we decided that the Plan does 
not have to pre-approve a clinical Crown Lengthening - Hard Tissue (D4249).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an IV injection and copayment for a CT 
scan provided by a participating provider on September 28, 2020. 
 
You asked the Plan to waive the coinsurance and copayment for an IV injection and a CT scan. You say that 
you do not agree with this charges. The Plan denied your request. The Plan says the correct coinsurance and 
copayment have 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 Medicare Part B prescription drugs/in-network and a $100 copayment for outpatient diagnostic 
tests/in-network/diagnostic radiology services/CT.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an IV injection and a $100 
copayment for a CT scan. The total allowed amount is $27.59. The coinsurance amount you are being asked to 
pay is $5.52 ($27.59 x 20% = $5.52). The total amount you are being asked to pay is $105.52 ($100 + $5.52 = 
$105.52). An IV injection falls within the Medicare Part B prescription drugs/in-network benefit category and a 
CT scan falls within the outpatient diagnostic tests/in-network/diagnostic radiology services/CT 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 an IV injection and copayment for a CT scan 
provided by a participating provider on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) (A4221, A4222, 
J2260) provided to the enrollee from March 20, 2020, to March 25, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service. 
 
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 and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, the billed code cannot be verified. 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 the 
durable medical equipment (DME) (A4221, A4222, J2260) provided to the enrollee from March 20, 2020, to 
March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluations (D0150), intraoral periapical 
x-rays (D0220), and removals of residual tooth roots (D7250) performed on October 22, 2019, and August 28, 
2020. 
 
You asked the Plan to pay for comprehensive oral evaluations, intraoral periapical x-rays, and removals of 
residual tooth roots. You say that you were overcharged for these claims. The Plan denied your request. The 
Plan says rules for payment have not been met. 
 
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. 
 
Regarding comprehensive oral evaluations performed on October 22, 2019, and August 28, 2020: 
 
The Plan covers one dental exam per calendar year. Based on review of the file, previous dental exams were 
provided fewer than twelve months prior to the visits at issue in this case. Therefore, we decided that the Plan 
does not have to pay for comprehensive oral evaluations (D0150) performed on October 22, 2019, and August 
28, 2020. 
 
Regarding intraoral periapical X-rays and removals of residual tooth roots performed on October 22, 
2019, and August 28, 2020: 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral periapical x-rays and 
removals of residual tooth roots were only covered under an additional, optional benefit in which you were not 
enrolled in 2019 or 2020. Therefore, we decided that the Plan does not have to pay for intraoral periapical x-
rays (D0220) and removals of residual tooth roots (D7250) performed on October 22, 2019, and August 28, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at a Skilled Nursing Facility. 
 
You asked the Plan to pre-approve continued stay at a Skilled Nursing Facility beyond February 12, 2021. You 
say that the enrollee needs a continued stay at a Skilled Nursing Facility. The Plan denied your request. The 
Plan says they will approve 7 more days but the enrollee does not meet criteria for continued SNF stay beyond 
that. 
 
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 continued stay at a Skilled Nursing 
Facility beyond February 12, 2021. Our reviewer says that daily skilled services are not necessary. Our 
physician reviewer found by the dates in question, the beneficiary was at a minimal to moderate assist level 
with functional mobility including gait to 5 feet with a rolling walker. The beneficiary required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs.  
 
 
 
The beneficiary does not require skilled nursing or therapy services on a daily basis.  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 continued stay at a Skilled Nursing Facility beyond February 12, 2021 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve continued stay at a Skilled Nursing 
Facility beyond February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6111) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 pre-approve 
dental services (D6111) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval for this out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers available for 
these services. 
 
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 
specialist services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you need a CGM. The 
Plan denied your request. The Plan says you do not meet the requirements for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a 
therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit on September 9, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that the charges exceed the $150 
deductible. The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $150 yearly deductible for your covered medical services and a $50 
copayment for in-network specialist?s office services. 
 
Review of the file shows that you received specialist services on September 9, 2020. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $150 yearly deductible for your covered 
medical services. This cost sharing is a contractual obligation that had not been met at the time these services 
were received on September 9, 2020. The Plan applied a total of $18.55 towards your yearly deductible for 
these services. At this time, your yearly deductible had been met. 
 
Given that the deductible charge did not cover the entire cost of the services, you have also been asked to pay a 
copayment for these services after the deductible was met. The Plan contract states that there is a $50 
copayment for in-network specialist?s office services. However, the remaining amount after the deductible 
charge was $31.46. Given that the remaining amount was less than the $50 copayment, you have been asked to 
pay $31.46 for these services. 
 
The total amount you have been asked to pay for these services is $50.01. This cost sharing is a contractual 
obligation that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not 
have to waive the cost sharing for the office visit on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received from February 25, 2020, to 
June 17, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
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 services are either not 
among those covered under this benefit, or are subject to a benefit limit. The Plan covers only those dental 
services listed in the Evidence of Coverage. The requested dental services (D3346, D0140, D9944, D6010, and 
D6104) are not covered. Additionally, the Plan covers one crown per calendar year. The records show that one 
crown was covered by the Plan for March 5, 2020. Any additional crowns exceed the benefit limit and are not 
covered. Therefore, we decided that the Plan does not have to pay for the dental services you received from 
February 25, 2020, to June 17, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve folinic acid, fluorouracil and irinotecan (FOLFIRI) and 
Bevacizumab. 
 
You asked the Plan to pre-approve FOLFIRI and Bevacizumab. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 FOLFIRI and Bevacizumab. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the requested use is FDA-
approved for the enrollee's diagnosis and documentation supports that the requested drug is safe and effective 
and otherwise reasonable and necessary for this 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 FOLFIRI and Bevacizumab have been met. Specifically, documentation 
supports the medical necessity of this service. Therefore, we decided that the Plan has to pre-approve folinic 
acid, fluorouracil and irinotecan (FOLFIRI) and Bevacizumab.  
 
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 pay for the vision services you received on October 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you must use an in-
network provider for these services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. The vision services were provided by an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the vision services you received on October 15, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction you received on September 29, 2020. 
 
You asked the Plan to pay for the extraction. You say that you needed to have the tooth removed. The Plan 
denied your request. The Plan says this 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 services are not among 
those covered under this benefit. The Plan covers oral exams, cleanings, periodontal maintenance, and x-rays. 
Dental extractions are not covered. Therefore, we decided that the Plan does not have to pay for the dental 
extraction you received on September 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services rendered from July 1, 2020, to 
August 1, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code H0019 is not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The billed procedure code H0019 has a status indicator of I and is not 
valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the behavioral health 
services rendered from July 1, 2020, to August 1, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care rendered from October 18, 2020 to 
October 19, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services 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 services were medically necessary. Our physician reviewer found the enrollee presented to the 
emergency department (ED) with malignant hypertension with markedly elevated refractory hypertension and 
headache. She was aggressively treated and admitted. The records support that, at the time of the inpatient 
admission, the admitting physician reasonably expected that two or more midnights of care would be medically 
necessary based on the enrollee's symptomatic presentation of refractory malignant hypertension. 
 
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 rendered from October 18, 2020 to October 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at at 
home with home health care, or in a long-term care setting. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does 
not meet Medicare criteria for IRF care. 
 
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.