Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for headgear used with positive airway pressure device (CPT 
Code A7035) provided on August 6, 2020. 
 
You asked the Plan to pay for the DME. You say that you cannot afford the portion of the bill that your plan 
denied. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The claim denied because your DME 
was reimbursed in accordance with the maximum allowable units for that code over a period of time. The Plan 
states your claims history for this equipment shows that it was billed/paid back on April 17, 2020, for one unit, 
which is only three months, two weeks and six days between claims. The Plan will only pay for the DME 
device once every six months per CMS guidelines. Therefore, we decided that the Plan does not have to pay for 
headgear used with positive airway pressure device (CPT Code A7035) provided on August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
May 23, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim was not received within the 365 day timely filing period. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric diagnostic evaluation was not filed until August 26, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) 
provided on May 23, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you are requesting that 
the $120 copayment be applied to your $150 deductible. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the ?Emergency 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 
emergency room visit provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cystoscopy (52000) provided. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 per visit for outpatient surgery.  
 
You have been asked to pay $109.64 (Plan allowed amount of $548.22 x 20% coinsurance) for the outpatient 
surgery provided. 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 the cystoscopy (52000) 
provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 14, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you have re-applied for in-
network status, but the Plan denied without cause. You also say that this enrollee resides in a nursing home, 
and your provider provides acute visits to the nursing home. The Plan denied your request. The Plan says the 
service was rendered by a non-participating provider. The Plan also says that prior authorization was not 
obtained. 
 
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 
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 subsequent nursing facility care provided on 
October 14, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 13, 
2020, to August 12, 2020. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing 
service needs and no identifiable skilled therapy service needs. In addition, the beneficiary did not require 
skilled nursing or therapy services on a daily basis and did 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from July 13, 2020, to August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 9, 
2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that your dentist took an x-ray and advised you 
that your tooth is infected. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation in 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, panoramic x-ray (D0330) is limited to 
one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on 
September 12, 2018, and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on May 28, 
2020. 
 
You asked the Plan to pay for the porcelain/ceramic crown. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the services are not covered under 
your supplemental dental 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. 
 
We looked at the file and Medicare rules. The file indicates that the porcelain/ceramic crowns were used for 
molar teeth which is specifically not covered by the Plan?s supplemental benefit. Based on this information, we 
decided that the Plan's rules for coverage of porcelain/ceramic crown have not been met Therefore, we decided 
that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5821), two pontics (D6245 
x2), and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the interim partial denture, pontics, and retainer crowns. You say that if a 
Plan covers crowns, then it must cover bridges. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim partial denture (D5821), two pontics (D6245 x2), and two retainer crowns (D6740 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, electronic connection, enhanced steering platform, and medical necessities bag for a power 
wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an electronic connection and expandable controller with harness are 
covered for specific indications. 
 
The requested power seat elevation system and medical necessities bag do not serve a purpose that is primarily 
medical in nature. Medicare does not cover these items. The requested electronic connection is not covered 
because the approved power options have their own electric switches. The expandable controller with harness 
is not needed to control the three power options through a joystick. The enhanced steering platform is included 
in the requested expandable controller. 
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable 
controller with harness, electronic connection, enhanced steering platform, and medical necessities bag for a 
power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 27, 2020, to 
June 29, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the inpatient care provided was 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 hospital care. Our reviewer 
says that the inpatient care provided starting June 28, 2020 was not medically necessary. Our physician 
reviewer found as of 12:29 p.m. on June 28, 2020, the enrollee was stable for ambulance transport with 
monitoring to a Plan facility because her medical condition was adequately treated. Her oxygen saturation 
stayed above 93% with no documentation of respiratory decline or need for acute change in oxygen delivery. 
The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was 
not stable for transfer on any dates of service. The care starting on June 28, 2020 was unauthorized post-
stabilization 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 the inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from June 27, 2020, to June 29, 2020, 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 topical application of fluoride varnish (D1206) provided 
on August 3, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that the service you received 
was medically necessary and would like the Plan to reconsider payment. 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 Plans 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 
topical application of fluoride varnish (D1206) provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior resin-based composite of one surface (D2391), 
two anterior resin-based composites of one surface (D2330 x2), two anterior resin-based composites of two 
surfaces (D2331 x2), four posterior resin-based composites of two surfaces (D2392 x4), unspecified procedure 
(D9908), and diagnostic casts (D0470) provided from June 26, 2020, to August 5, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the resin-based composites, unspecified procedure, and diagnostic casts. You say 
that you have seen this provider for many years. You also say that you cannot go to an in-network dentist 
because of your condition. The Plan denied your request. The Plan says payment has been issued to you for the 
Plan's share of your covered dental services. The Plan also says that you are responsible for the cost share of 
the covered services and the denial of the non-covered services. 
 
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 unspecified procedure and 
diagnostic casts are not among those covered under this benefit. The contract also clearly states that you must 
pay a 70% coinsurance for each restorative service provided out-of-network. Therefore, we decided that the 
Plan does not have to pay for the posterior resin-based composite of one surface (D2391), two anterior resin-
based composites of one surface (D2330 x2), two anterior resin-based composites of two surfaces (D2331 x2), 
four posterior resin-based composites of two surfaces (D2392 x4), unspecified procedure (D9908), and 
diagnostic casts (D0470) provided from June 26, 2020, to August 5, 2020, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (including flap entry and closure) and 
(D4261x2) non-intravenous conscious sedation (D6248) provided August 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the reason that you are appealing is because this 
was a necessary surgery for your health for the rest of your life. The Plan denied your request. The Plan says 
these services are not covered under the plan 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, 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 osseous 
surgery (including flap entry and closure) and (D4261x2) non-intravenous conscious sedation (D6248) 
provided August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (73630) provided on October 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were not emergent and 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 services at issue in this appeal. The Plan did not pre-approve the 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 an x-ray (73630) provided on October 15, 2020 by an out of network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that this is not covered 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 Novolog for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One for the enrollee. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agent(s) would likely be less effective, and/or 
cause adverse effects for the member. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed 
Orthovisc and Monovisc. There is no indication that the plan's required drug(s) would likely be less effective 
and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition 
does not meet step therapy criteria for Gel-One. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 23, 2020, to 
January 25, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the inpatient care was not medically necessary and 
a lower level of care would have been appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency room on January 23, 2020, with complaints of 
lightheadedness and chest pain. She was found to be in atrial fibrillation. The member was admitted for further 
treatment. Cardiology was consulted with recommendations to control blood pressure, continue Coumadin as 
she has a metallic AVR and consult electrophysiology. The review has determined that the record showed that 
at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 23, 2020, to January 25, 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.