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

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that your current dentures are too big and hurt your gums. The Plan denied your request. The Plan says these 
services 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
February 12, 2020, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three core buildups, including any pins when required 
(D2950 x3). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
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 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 three 
core buildups, including any pins when required (D2950 x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transport and set up of portable x-ray equipment (R0075 
and Q0092) provided on February 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for transport and set up of portable x-ray equipment. You say that the services 
rendered were medically necessary. The Plan denied your request. The Plan says services must be obtained 
from an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the transport and set up of portable x-ray 
equipment (R0075 and Q0092) provided on February 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 21, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the medical records support the medical 
necessity of the services. The Plan denied your request. The Plan says non-emergent services by non-
participating 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 you must get a referral from the PCP prior to getting care from out-of-network providers via the 
Point of Service benefit.  
 
The 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 the lab services provided on May 21, 2020 by an out of network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided from August 24, 2019, to August 25, 
2019, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that you would like reconsideration because 
you were suffering a mental health crisis and this creates financial hardship. The Plan denied your request. The 
Plan says that you do not have out-of-network benefits. 
 
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. 
 
We looked at your request, the file and rules. Based on this information we have decided that rules for payment 
have been met. Specifically, the record does not include evidence that the Plan made a good faith effort to 
acquire medical records from you or your provider to determine if these services were emergent. It is the 
burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated, 
and we must find in your favor. Therefore, we decided that the Plan has to pay for the medical services 
provided from August 24, 2019, to August 25, 2019, by an out-of-network (OON) provider.  
 
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 lab services provided to the enrollee on December 21, 2019. 
 
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 Medicare billing criteria as stated above are not met.  
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99335) provided 
on June 12, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient assisted living visit (99335) 
provided on June 12, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on July 28, 
2019. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not include the time spent providing this service. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services coded 99291 provided on July 28, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that a SNF stay is medically necessary. You say 
that the enrollee cannot walk or do anything on their own, and is bed ridden. You say that the doctors at the 
hospital state that the enrollee desperately needs therapy. The Plan denied your request. The Plan says the 
enrollee does not need more skilled therapy that cannot be performed at another 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs, was treated for pneumonia, and used oxygen via a 
nasal cannula. The enrollee was at a minimal to maximal assist level with functional mobility. The enrollee 
required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. 
 
 
There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on August 4, 2019. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration because 
the services rendered were medically necessary The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate the 
amount of time spent rendering critical care services. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291) provided on August 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on August 20, 2019. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you would like this taken care 
of immediately. The Plan denied your request. The Plan says the correct copayment has been applied.  
 
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 $225 
copayment for ambulance services/ground.  
 
You have been asked to pay a $225 copayment for an ambulance trip. Since an ambulance service was 
provided, the correct copayment has been applied. An ambulance trip falls within the ambulance 
services/ground 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 an ambulance trip 
provided by a participating provider on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter supplies (A4349, A4353 and A4357) provided on 
October 22, 2019. 
 
You asked the Plan to pay for the catheter supplies. You say that you would like reconsideration because the 
supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted 
does not include an itemized billing/shipping invoice or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice to verify the supplies billed. 
Additionally, the documentation does not include a proof of delivery for the billed date of service. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for catheter supplies (A4349, A4353 and A4357) provided on 
October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 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 Medicare billing criteria were not met. The Plan says that the medical records show the 
enrollee had a comprehensive genomic profile (CGP) testing on May 13, 2020. The denial remains upheld as 
there is a more appropriate code to describe the services provided. 
 
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, this claim was billed with an 
inappropriate code. Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on May 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of 
Durolane, Gelsyn-3, and Synvisc/Synvisc-One before they will approve the requested drug. Based on the 
medical records provided, the enrollee has not tried and failed the required drugs, and there is no indication that 
the required drugs would likely be less effective or have adverse effects for the enrollee in this case. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic, prophylactic, or diagnostic 
injection provided on February 19, 2020. 
 
You asked the Plan to waive the copayment for therapeutic, prophylactic, or diagnostic injection (96374). You 
say that you have copayments for the ultrasound and should not have a separate copayment for the injection. 
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 $295 
copayment for Outpatient Facilities.  
 
You have been asked to pay a $173.13 for therapeutic, prophylactic, or diagnostic injection (96374). 
therapeutic, prophylactic, or diagnostic injection (96374). This amount is less than your copayment. This 
service falls within the Outpatient Facilities 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 therapeutic, prophylactic, or diagnostic injection provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the Group 3 PWC. You say that the requested PWC is medically necessary 
to treat the enrollee's mobility limitation. The Plan denied your request. The Plan says the enrollee does not 
have a covered diagnosis for this PWC. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 a knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates that the enrollee does not have any of the covered conditions for 
this brace. The requested knee orthosis is not medically necessary or reasonable. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1845).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80048, 84153) provided on February 
18, 2020, to March 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were under the impression that 
laboratory services would be covered out of network. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (80048, 84153) provided 
on February 18, 2020, to March 13, 2020 by an out of network (OON) provider.