Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided out of network on September 16, 
2020. 
 
You asked the Plan to pay for out of network providers. You say that this service should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 physician services provided 
out of network on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided to the enrollee from July 20, 
2020, to August 13, 2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 services. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided to the enrollee from 
July 20, 2020, to August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on May 26, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were necessary. The Plan denied 
your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 May 22, 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 the subsequent hospital care 
provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) to be rendered by 
an OON provider. 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you got your current denture 
in March of 2015, and it is broken. You also say that you need a new denture because you cannot eat solid 
food. The Plan denied your request. The Plan says the Plan failed to review this appeal in a timely manner. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) to be rendered by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no trial and failure of other treatment prescribed by a doctor. 
 
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 the surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Comprehensive Musculoskeletal Management Guidelines CMM 315 indicate that surgery is not 
appropriate unless there is a failure of a trial of conservative treatment to resolve the enrollee's condition.  In 
this case, there is no evidence that the enrollee has received a reasonable and comprehensive trial of 
conservative treatment prior to this request. Therefore, this request does not meet Medicare criteria as 
medically reasonable and necessary for the treatment of this enrollee's medical condition.  
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve shoulder surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug and the injection provided 
on August 25, 2020. 
 
You asked the Plan to waive the cost share for the Part B drug and the injection. You say that the provider did 
not mention the coinsurance for the medication prior to receiving the service. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment per visit to a specialist.  
 
You have been asked to pay a total of $195.40 for the Part B drug and the injection. The Part B drug falls 
within the Medicare Part B prescription drugs benefit category. The injection falls within the Physician/ 
Practitioner services, including doctor?s office visits? benefit category. See chart below. 
  
 
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
August 25, 2020 Part B medication $876.96 20% $175.40 
August 25, 2020 Injection $93 $20 $20 
Total    $195.40 
 
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 a Part B drug and injection provided on August 
25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic reading services (CPT 93010) provided to the 
enrollee on August 1, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says without a physician's interpretation, note, and signature, computer-generated EKG reports do not 
meet the requirements for the professional component of an EKG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93010 is ?Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only.
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found separate 
reimbursement is not allowed for CPT 93010 when submitted with the following services: emergency room 
Evaluation and Management CPT 99281 - 99285; critical care Evaluation and Management CPT codes 99291 - 
99292.  Interpretation of the ECG report by the attending physician is considered part of the Evaluation and 
Management visit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for diagnostic reading services (CPT 93010) provided to the enrollee on August 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair ramp rental provided from July 26, 2020, to 
November 26, 2020. 
 
You asked the Plan to pay for wheelchair ramp rental. You say that this equipment was medically necessary. 
The Plan denied your request. The Plan says wheelchair ramps are not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare does not cover wheelchair ramps of any kind. Therefore, we decided that the Plan 
does not have to pay for wheelchair ramp rental provided from July 26, 2020, to November 26, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve two retainer crowns for teeth #28 and 30, and a pontic for tooth 
#29. 
 
You asked the Plan to pre-approve the dental services. You say that a bridge and crown are the best course of 
treatment. The Plan denied your request. The Plan says that the dentist did not indicate why a denture cannot be 
used to replace the 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 dental 
services 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 dental services. Our reviewer says 
that the bridge is medically necessary. Our physician reviewer found the provided documentation indicates that 
the current fixed bridge replacing tooth #29 is defective. The reviewer found that the bridge needs to be 
replaced. Therefore, the reviewer found that a replacement fixed bridge to replace tooth #29 with a pontic and 
using teeth #28 and 30 as abutment retainers is reasonable and necessary and meets the criteria for coverage. 
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve two retainer crowns for teeth #28 and 30, and a pontic for tooth #29.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert system. 
 
You asked the Plan to pre-approve a medical alert system. You say that a medical alert system is medically 
necessary. The Plan denied your request. The Plan says a medical alert system is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover precautionary devices. A medical alert system 
is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a medical alert system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that your current denture has a hole in it. You also 
say that you are having a hard time keeping it in. The Plan denied your request. The Plan says 1 upper denture 
is covered every 60 months. The Plan also says that the frequency limit has been reached. 
 
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 frequency limit of 1 upper denture 
per 60 months has been reached. The record shows that the Plan paid for an immediate upper denture (D5130) 
that you received on July 10, 2020, less than 60 months ago. Therefore, we decided that the Plan does not have 
to pre-approve a complete upper denture (D5110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 
25, 2020, to April 1, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the enrollee was discharged from the hospital 
with increased weakness, poor balance, abnormal gait and mobility. You say that the enrollee was not 
evaluated for Activities of Daily Living (ADLs). You say that the enrollee was unsafely discharged from the 
hospital on January 2, 2020. You also say that documentation shows that the enrollee was unable to do 
functional ADLS on her own, which necessitate an SNF level of care. The Plan denied your request. The Plan 
says the enrollee's stay did not meet the inpatient criteria. The Plan says that the care that you received could 
have been provided without an inpatient stay. 
 
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 services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist during the dates in question. The enrollee did not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from January 25, 2020, to April 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wicks for the noncovered catheter system. 
 
You asked the Plan to pay for wicks for the noncovered catheter system. You say that the wicks are medically 
necessary. The Plan denied your request. The Plan says the requested supplies are for a noncovered Medicare 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that this system is not approved for Medicare 
coverage.  
 
We looked at the file and Medicare rules. Medicare does not cover this brand of catheter system therefore; the 
supplies are not covered. We decided that the Plan does not have to pay for wicks for the noncovered catheter 
system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on June 11, 2020. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the 
right to recover for services provided to eligible beneficiaries is not extinguished by specific plan requirements. 
The Plan denied your request. The Plan says these services were not billed in accordance to Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that these services are not supported in the record. Specifically, this claim was not billed with the 
appropriate revenue code. Based on this information, we decided that Medicare rules for coverage of the 
hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
services provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the inpatient hospital services provided on 
January 16, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were not provided a room 
for your inpatient stay. The Plan denied your request. The Plan says the claim processed 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 $255 
copay per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $255 copay for the services provided. The services fall within the inpatient 
hospital 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 copay for the inpatient hospital services 
provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI injection. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
previous injection reported 20% relief of pain but repeat injection requires at least 50% pain relief. 
 
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 SI injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found repeat SI injections are only indicated if the initial injection results in at least 50% pain relief 
and an improvement in patient-specific activities of daily living for at least 6 weeks after the previous injection. 
In this case, the enrollee reported about 20% relief of pain from this injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you would like 
reconsideration because this transportation is necessary to get to appointments. The Plan denied your request. 
The Plan says this services exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral appliance to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the oral appliance. You say that the enrollee needs the oral appliance to treat 
sleep apnea. You say that there are no network providers that can render the service. The Plan denied your 
request. The Plan says the enrollee's contract does not have coverage for out-of-network providers. The Plan 
also says that participating providers are available to provide the service and equipment.  
 
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 oral appliance to be provided by an out-of-network provider.