Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services 
provided on May 6, 2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says the Plan requires utilization of network providers when possible and available, and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented.   
 
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 
services at issue. 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 psychiatric diagnostic evaluation with medical services provided 
on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 20, 21 and 28. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has tooth decay. You also say 
that the services should be approved. The Plan denied your request. The Plan says that core build up is not 
listed as a covered service.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for teeth # 20, 21 and 28.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary visit (99325) provided on February 14, 2020. 
 
You asked the Plan to pay for domiciliary visit. You say that the hospice benefits were revoked prior to the date 
of service. The Plan denied your request. The Plan says the fee-for-service (FFS) benefit is the time where the 
member revokes hospice until the start of the new month. During this time Traditional or Original Medicare is 
still responsible for payment of medical services both unrelated and related to the hospice diagnosis.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 13, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for domiciliary visit 
(99325) provided on February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve the Xifaxan tablets. You say that the drug in dispute is medically necessary 
for treatment of the enrollee's irritable bowel syndrome. The Plan denied your request. The Plan says they do 
not cover outpatient prescription drugs. 
 
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 Xifaxan tablets.  
 
Benefits for the Xifaxan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation. 
 
You asked the Plan to pre-approve the dental service. You say that your teeth had to be repaired as a result of 
chemotherapy that you received. You say that this should be covered under your medical insurance benefit and 
not dental. You also say that you expect to receive the amount that would have been paid to an in network 
dentist. The Plan denied your request. The Plan says the requested service is dental in nature. The Plan also 
says that the requested service is not covered under your medical coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pre-approve 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. Therefore, we decided that the Plan does not have to pre-approve a consultation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 7, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. 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 subsequent nursing facility care provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the orthopedic surgery office visit you had 
on August 26, 2020. 
 
You asked the Plan to waive the copayment for the orthopedic surgery office visit. You say that you had a 
major surgery that required multiple follow-up visits.  You stated that until the visit on August 26, 2020, you 
had not been charged an office visit copayment for any of these follow-up visits. The Plan denied your request. 
The Plan says office visit copayments for post-operative visits during the global surgical period are included in 
the cost of the surgery.  However, the office visit on August 26, 2020 was outside of the 90-day global surgical 
period.  This is why your previous follow-up visits did not have a copayment, but this one did. 
 
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 $45 
copayment for office visits with a specialist.  
 
You have been asked to pay a $45 copayment for the orthopedic surgery office visit. This follow-up visit 
occurred outside of the 90-day global surgical period. 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 orthopedic surgery office visit you had on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on May 2, 2019. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that the enrollee's 
benefit plan does not provide coverage for services rendered by a provider who is not in their specific HMO 
Network.  The only exceptions are emergencies, urgently needed services when the network is not available, 
dialysis services for enrollee's with end-stage renal disease (ESRD) when traveling outside the Plan?s service 
area, and cases in which the Plan prior authorizes use of out of network providers. 
 
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 
drug test. 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 a drug test provided on May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to three teeth 
per quadrant (D4342). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under 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. This service is not listed in your handbook as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - one to three teeth per quadrant (D4342).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from 
January 4, 2020, to January 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were given 
incorrect information about how much you should owe. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that it had to reprocess this claim twice, but ultimately, the 
copayment was assessed in accordance with your Plan benefits. 
 
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 $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-5 for the inpatient hospital care. 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 inpatient hospital care you received from January 4, 2020, to January 
10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says this procedure is not on the inpatient only list and does not meet 
criteria for inpatient level of care. The Plan states this can be performed in an outpatient or observation hospital 
setting. The Plan states the services can be performed in an outpatient or observation hospital setting. 
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of acute inpatient hospital care have not been met. The requested procedures are approved for 
observation/outpatient level of care as they do not meet the criteria for inpatient designation. Submitted records 
do not show that you have any medical conditions that requires inpatient level of care. Therefore, we decided 
that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the orthopedic surgery office visit you had 
on September 15, 2020. 
 
You asked the Plan to waive the copayment for the orthopedic surgery office visit. You say that this visit was 
needed due to a previous injury that is recurring. The Plan denied your request. The Plan says you were 
charged this copayment correctly. Please note that the Plan has reprocessed the cost sharing charged for the x-
ray and triamcinolone injection you received on this same date of service and you only owe the office visit 
copayment. 
 
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 $45 
copayment for specialist visits.  
 
You have been asked to pay a $45 copayment for the orthopedic surgery office visit. 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 orthopedic surgery office visit you had on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation (64625). You say that the requested radiofrequency 
ablation (64625) is medically necessary. The Plan denied your request. The Plan says the requested 
radiofrequency ablation (64625) 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 radiofrequency ablation (64625). Our 
reviewer says that the requested radiofrequency ablation (64625) is not medically necessary. Our physician 
reviewer found the enrollee has chronic low back pain. She had RFA of the MBBs. She is taking Gabapentin, 
Norco and Baclofen. The request is for RFA of the bilateral SI joints. This procedure is considered 
experimental/investigational due to the wide variation in efficacy in the peer reviewed literature.  Therefore, the 
requested procedure is considered not medically reasonable or 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 radiofrequency ablation (64625) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood draws through the home health care benefit. 
 
You asked the Plan to pre-approve blood draws through the home health care benefit. You say that the 
requested blood draws through the home health care benefit is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for blood draws through the home health care benefit. 
 
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 blood draws through the home health 
care benefit. Our reviewer says that the enrollee does not meet criteria for blood draws through the home health 
care benefit. Our physician reviewer found the enrollee is with a past medical history of dementia and thyroid 
disease. A blood draw through the home health care benefit to monitor her thyroid function has been requested. 
Based on the medical records provided there is no documentation that the enrollee meets the above criteria for 
the requested blood draw through the home health care benefit. The provided records do not document that the 
enrollee qualifies for home health eligibility based on a skilled need other than solely needing the venipuncture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blood draws through the home health care benefit have not been met. Therefore, 
we decided that the Plan does not have to pre-approve blood draws through the home health care benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3348) 
provided on August 20, 2020. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you cannot afford to 
pay for this. The Plan denied your request. The Plan says this service is not a covered benefit under your 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 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 
retreatment of previous root canal therapy (D3348) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine optometry services (92015, 92004, 92341) 
provided on July 16, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine optometry services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for the 
services and there are multiple in-network providers available to meet your medical needs.
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. In this case, the provider was not in-network with the Plan. No prior 
authorization was obtained before the services rendered. Based on this information, we decided that the Plan's 
rules for coverage of the routine optometry services have not been met. Therefore, we decided that the Plan 
does not have to pay for the routine optometry services (92015, 92004, 92341) provided on July 16, 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 eye exam (92014 and 92015) provided on July 16, 2020. 
 
You asked the Plan to pay for eye exam. You say that the service was medically necessary. The Plan denied 
your request. The Plan says there are provider's in-network that could provide this service. 
 
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. 
 
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 one comprehensive eye exam, complete frame, and pair of lenses (contact lenses, if 
medically necessary) are covered: per 12-month period for members under 21 and over 59 years of age; or per 
24-month period for members 21 through 59 years of age. 
 
We looked at the file and the Plan's rules. The member received care from an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of eye exam have not been met. Therefore, 
we decided that the Plan does not have to pay for eye exam (92014 and 92015) provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Losartan Potassium 100 mg tablet. 
 
You asked the Plan to pre-approve the Losartan Potassium. You say that this drug is medically necessary to 
treat the enrollee's condition The Plan denied your request. The Plan says this is not a medical necessity denial. 
This drug is not covered for your condition by your Part B Plan. 
 
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 the Losartan Potassium 100 
mg tablet.  
 
Benefits for the Losartan Potassium 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete maxillary denture provided on 
November 4, 2019. 
 
You asked the Plan to pay for the reline of a complete maxillary denture. You say that you were told that you 
had full coverage for the reline. The Plan denied your request. The Plan says this service is 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 pay for the reline 
of a complete maxillary denture provided on November 4, 2019.