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

We decided that the Plan does not have to pay for the catheter drainage, non-laser introducer/sheath, exchange 
of biliary drainage catheter, moderate sedation services, Midazolam Hydrochloride injection, Fentanyl Citrate 
injection, and low osmolar contrast material provided on April 3, 2020. 
 
You asked the Plan to pay for the catheter drainage, non-laser introducer/sheath, exchange of biliary drainage 
catheter, moderate sedation services, injections, and low osmolar contrast material. You say that this claim has 
not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the catheter drainage, non-laser introducer/sheath, exchange 
of biliary drainage catheter, moderate sedation services, Midazolam Hydrochloride injection, Fentanyl Citrate 
injection, and low osmolar contrast material provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided to the enrollee on 
April 27, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that this item was medically necessary. 
The Plan denied your request. The Plan says that documentation indicates services are not necessary for 
treatment of the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator provided to the enrollee on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99350) provided on June 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that you were informed you did not need authorization. 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 home visit (99350) provided on June 17, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care (11042) provided on July 9, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for OON wound care. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 wound care (11042) provided on July 9, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 16, 2020. 
 
You asked the Plan to pay for the physician's services. You say that you called this provider's office and you 
were told they take your insurance plan. The Plan denied your request. The Plan says you 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 June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on June 23, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that the Plan is to pay 100% for fillings. The 
Plan denied your request. The Plan says you received the correct coverage for the resin-based composite filling. 
The Plan also says that a composite resin restoration on a posterior tooth is not a benefit of the dental 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 Plan will pay only the amount that 
it would have paid to restore a posterior tooth with amalgam, and you are responsible for the difference in cost. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on June 23, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #'s 6 through 11. 
 
You asked the Plan to pre-approve crowns for tooth #'s 6 through 11. You say that the enrollee has severe wear 
on anterior maxillary teeth, a collapsed bite and sensitivity. You say that these teeth need full coverage crowns 
to avoid root canals. The Plan denied your request. The Plan says the crowns are not medically necessary. 
 
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. The Plan covers crowns when 
the services are medically necessary and reasonable.  
 
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 crowns for tooth #'s 6 through 11. Our 
reviewer says that the crowns are not medically necessary. Our physician reviewer found that there is no clear 
indication of any decay or fractures that would have affected the involved teeth. Our reviewer says that due to 
the lack of any history of caries or recent fracture, and the history of incisal wear, the criteria for crowns under 
the policy is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns for tooth #'s 6 through 11 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve crowns for tooth #'s 6 through 11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital clinic visit (G0463) and prothrombin 
time (85610) provided on May 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for hospital visit and clotting time blood test. You say that you are the closest 
hospital to the patient. 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 outpatient hospital clinic visit (G0463) and 
prothrombin time (85610) provided on May 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist and pathology services 
provided on May 5, 2020. 
 
You asked the Plan to waive the cost share for the specialist and pathology services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received specialist and pathology services on the date of 
service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the 
Plan. 
 
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 $35 
copayment for services provided by a specialist.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an office visit 
provided by a specialist on May 5, 2020. You have been asked to pay a $35 copayment for the specialist 
services. The specialist services fall within the Physician/Practitioner services benefit category.  
 
Your contract with the Plan also says your in-network deductible is $300. This is the amount you have to pay 
out-of-pocket before the Plan will pay their share for your covered in-network services. The file shows that you 
have been asked to pay $103.60 towards your deductible for the pathology services you received on May 5, 
2020. This cost sharing is a contractual obligation that had not been met at the time you received the pathology 
 
 
services. 
 
This means that you have been asked to pay the correct amounts 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 cost share for the specialist and pathology services provided on May 5, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole tablets. 
 
You asked the Plan to pre-approve Pantoprazole tablets. You say that the enrollee is having a lot of problems 
with gastroesophageal reflux disease. You also say that the enrollee is not currently on any medication, due to 
the withdrawal of Ranitidine from the market. The Plan denied your request. The Plan says this drug does not 
fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole tablets.  
 
Benefits for Pantoprazole tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by a chiropractor on March 6, 2019. 
 
You asked the Plan to pay for office visit. You say that you were told that this provider was in-network, and 
you are on a fixed income and cannot afford to have money slip through your fingers. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because this service is not covered by 
Medicare or the Plan when performed by a chiropractor. The Plan also says that they have approved payment 
for the chiropractic manipulation treatments, so the remaining denial is only for the office visit charge for 
March 6, 2019. 
 
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 an office visit provided by a chiropractor on March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on November 21, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you need assistance paying your medical bills. The Plan 
denied your request. The Plan says prior authorization must be obtained for 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 outpatient office visit (99214) provided on 
November 21, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6242) for tooth #30 and retainer crowns 
(D6752) for tooth #'s 29 and 31. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the enrollee has no other teeth 
missing on her mandible, other than her wisdom teeth, leaving no teeth to place on the partial. The Plan denied 
your request. The Plan says the bridge is not medically necessary at this time. The Plan also says that the 
documentation does not show why a denture cannot be used to replace the enrollee's missing teeth. 
 
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. The Plan covers the pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontic and retainer crowns. Our 
reviewer says that these services are not medically necessary. Our physician reviewer found the bone support 
on the available abutments looks adequate to support a bridge as indicated. The policy has noted specific 
instances where coverage would be allowed for a fixed appliance. The limitations preclude a fixed bridge 
except in cases where there is a neurological or physical medical condition that would not allow for the use of a 
removable appliance. Our reviewer found that the provided documentation does not indicate any condition of 
the member that would not allow for the use of a removable appliance. Our physician reviewer also found that 
given the supplied materials, and the lack of any medical or neurological conditions of the enrollee, there 
would be no necessity for the requested fixed bridge. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6242) for tooth #30 and retainer crowns (D6752) for tooth #'s 
29 and 31.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you need rehabilitation to build enough 
strength to live at home. The Plan denied your request. The Plan says the denial of authorization for SNF 
service is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
Skilled Nursing Facility (SNF) setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on March 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 29, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device/appliance provided on August 15, 2019. 
 
You asked the Plan to pay for the oral device/appliance. You say that this service is medical in nature, not 
dental, and should be reprocessed. The Plan denied your request. The Plan says charges for dental and dental 
related services are not covered under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom fabricated mandibular advancement 
oral appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered if the enrollee has had a 
Medicare-covered sleep test that shows a certain severity of the condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oral device/appliance have not been met. Therefore, we decided that the Plan does not have to 
pay for the oral device/appliance provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on November 4, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for office 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 office outpatient visit (99214) provided on 
November 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR genetic testing. 
 
You asked the Plan to pre-approve MTHFR test. You say that this testing is needed to determine if the enrollee 
is at a higher risk of developing venous thromboembolism. The Plan denied your request. The Plan says the 
denial of authorization for this testing is correct, because MTHFR testing is not considered to be clinically 
efficacious. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MTHFR test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found most hematological experts, including the American Society of Hematology, recommend not 
testing for MTHFR in any setting. It is not considered to be a significant cause of hypercoagulability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MTHFR test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MTHFR genetic testing.