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

 
We decided that the Plan does not have to pay for the crown you received on July 29, 2020. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. You were not enrollee in the Plan's supplemental dental rider at the time the crown was 
provided. Therefore, we decided that the Plan does not have to pay for the crown you received on July 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations provided to the enrollee on September 3, 
2019. 
 
You asked the Plan to pay for immunizations under Medicare Part B. You say that this claim should be paid. 
The Plan denied your request. The Plan says immunizations are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunizations 
under Medicare Part B. The Plan follows the same rules. The records do not show the enrollee was injured or 
directly exposed to any illness related to immunizations under Medicare Part B. Therefore, we decided that the 
Plan does not have to pay for immunizations provided to the enrollee on September 3, 2019.  
 
Benefits for immunizations 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Superion Interspinous Decompression. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the type of service requested s not supported because research has 
not found it to be helpful for your condition or for what is causing your pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the your 
condition does not meet Medicare criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Superion Interspinous Decompression.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a pair of depth shoes (A5500) and inserts (A5513).

You asked the Plan to pre-approve a pair of depth shoes (A5500) and inserts (A5513). You say that the
requested depth shoes (A5500) and inserts (A5513) are medically necessary. The Plan denied your request. The
Plan says that the enrollee does not meet criteria for the requested pair of depth shoes (A5500) and inserts
(A5513).

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 a pair of depth shoes (A5500) and
inserts (A5513). Our reviewer says that the enrollee meets criteria for the requested pair of depth shoes
(A5500) and inserts (A5513). Our physician reviewer found the enrollee is diagnosed with type 2 diabetes
mellitus. We are told he has foot deformity and diminished sensation in his legs. He is requesting a well fitted
pair of shoes; apparently the shoes he received did not fit well and caused infection or irritation on his foot. He
has a foot deformity and diabetes mellitus and meets the LCD criteria for the requested shoes and inserts.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a pair of depth shoes (A5500) and inserts (A5513) have been met. Therefore,
we decided that the Plan has to pre-approve a pair of depth shoes (A5500) and inserts (A5513).

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing (81479) provided on June 
24, 2020. 
 
You asked the Plan to pay for the Genesight Psychotropic testing. You say that you would like reconsideration 
because this testing is covered by Medicare. The Plan denied your request. The Plan says this test needs to be 
ordered by a licensed psychiatrist or neuropsychiatrist. 
 
The Plan must follow Medicare rules. Medicare rules say that Genesight testing may only be ordered by 
licensed psychiatrists or neuropsychiatrists. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Genesight Psychotropic testing have not been met. Specifically, the record does not indicate 
that this test was ordered by a licensed psychiatrist or neuropsychiatrist. Therefore, we decided that the Plan 
does not have to pay for the Genesight Psychotropic testing (81479) provided on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care you 
received on March 20, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you would like this copayment 
waived. The Plan denied your request. The Plan says the copayment applied 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 $0 
copayment for days 1-20 and a $178 copayment for days 21-100 for skilled nursing facility care.  
 
You have been asked to pay a total cost share of $2136 ($178 copayment x 12 days). The Plan has already 
reviewed your SNF claim for the month of April and so these dates in March are not considered to be days 1-20 
of your SNF stay. The services provided fall skilled nursing facility care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the skilled nursing facility (SNF) care you received on March 20, 
2020 to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services you received on April 
8, 2020. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you went back for a 
recheck visit and were never told a $65 copayment would apply. 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 $65 
copayment for urgent care visits.  
 
You have been asked to pay a $65 copayment for the urgent care services. This copayment applies each time 
you visit an urgent care facility. 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 urgent care services you 
received on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85025, P9604, 36415) provided on July 1, 
2020. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 lab services (85025, P9604, 36415) provided 
on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that the requested genetic testing is medically 
necessary. The Plan denied your request. The Plan says the requested genetic testing is not medically 
necessary. 
 
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 genetic testing. Our reviewer says that 
the requested genetic testing is not medically necessary. Our physician reviewer found the enrollee is with 
metastatic uterine cancer. Per NCCN guidelines for hereditary cancer testing, endometrial cancer is not an 
indication for BRCA1/2 testing. The requested genetic testing is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the air ambulance transportation provided on August 19, 2019. 
 
You asked the Plan to pay for the transportation services. You say that the enrollee required immediate 
response for pain in his upper chest from a seat belt. The Plan denied your request. The Plan says that other 
means of transportation could have been used without endangering the enrollee's health. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the transportation services. Our physician 
reviewer found that the enrollee was in a motor vehicle accident, and suffered acute chest trauma and chest 
pain. The air ambulance was indicated due to the potential for a more serious complication requiring a chest 
tube or some other type of intervention as result of trauma. Therefore, the provided transportation was 
medically reasonable and necessary to treat the 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 the transportation services have been met. Therefore, we decided that the Plan 
has to pay for the air ambulance transportation provided on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the infusion services. You say that you would like reconsideration because 
there is not an in-network pharmacy that provides this service. The Plan denied your request. The Plan says 
medically necessary care is available in-network. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral X-
rays (D0210). 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral X-rays. You say that the services 
are medically necessary for your condition. The Plan denied your request. The Plan says the services requested 
exceed the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral evaluation and intraoral X-rays once every three years when medically reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The file indicates that you already received these services in August 
2020; therefore, you have exhausted your Plan benefit for the services requested. Based on this information, we 
decided that the Plan's rules for coverage of the comprehensive oral evaluation and intraoral X-rays have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) and intraoral X-rays (D0210).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from July 13, 2020 to August 17, 
2020. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary and are 
covered by Medicare. The Plan denied your request. The Plan says the denial of payment for these physical 
therapy services is correct, because the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee's high functional level did not appear to require 
the unique skills of a professional therapist to safely and effectively provide treatment. The services did not 
need to be performed only by a therapist to be safe and effective and they did not need to be under the 
supervision of a therapist. The specialized skill, knowledge, and judgment of a qualified therapist was not 
 
 
required to establish, design, and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for physical therapy provided from July 13, 2020 to August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a GeneSight Psychotropic gene panel (81479) provided on 
June 9, 2020. 
 
You asked the Plan to pay for a GeneSight Psychotropic gene panel. You say that this was medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by 
licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication 
 
We looked at the file and Medicare rules. The submitted medical records show that the GeneSight testing at 
issue was not ordered by a licensed psychiatrist or neuropsychiatrist contemplating an alteration in 
neuropsychiatric medication. Based on this information, we decided that Medicare rules for coverage of a 
GeneSight Psychotropic gene panel have not been met. Therefore, we decided that the Plan does not have to 
pay for a GeneSight Psychotropic gene panel (81479) provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had at an outpatient 
hospital facility on June 2, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you don't feel as though you 
should have to pay this copayment.  You say that if you had gone to a different facility, there would not have 
been a copayment for this testing. 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 $10 
copayment for lab services performed in an outpatient hospital facility.  
 
You have been asked to pay a $10 copayment for the lab services. Under your Plan's contract, the copayment 
for lab services is based on the place of service, not the service itself. 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 lab services you had at an outpatient hospital facility on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided on January 15, 2020. 
 
You asked the Plan to pay for the inpatient post-stabilization care. You say that the inpatient post-stabilization 
care provided was medically necessary. The Plan denied your request. The Plan says that the services provided 
were unauthorized post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the inpatient post-stabilization care. Our 
reviewer says that the services the enrollee received were reasonable and medically necessary. Our physician 
reviewer found the facility acted in good faith and notified the Plan on the status of the patient while the Plan 
failed to meet standards of timely disposition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital care provided on January 15, 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 pay for skilled nursing facility (SNF) care provided on September 
22, 2019, through September 30, 2019. 
 
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 could have been done at lower 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily basis and there are no identifiable skilled therapy service needs. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on September 22, 2019, through September 30, 2019.