Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 29, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 had network providers 
available who could have provided 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 provided on September 29, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would greatly benefit from an intense rehab 
program, so you can gain the strength and endurance to perform your daily activities at home. The Plan denied 
your request. The Plan says your request is not medically necessary because your records show you do not 
require frequent rehabilitation physician management. The Plan also says that your rehabilitation needs are not 
complex and do not require an interdisciplinary approach with multiple specialists to oversee your 
rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician 
reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the panoramic x-ray 
(D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided from 
September 24, 2019 to November 19, 2019. 
 
You asked the Plan to pay for the dental services. You say that your case manager did everything and made 
sure that everything was in network. You say that the provider did not put in the correct codes for the dentures. 
You say that you were advised the dentist would not see you until the bill for the dentures was paid. You also 
say that this is not your fault at all. The Plan denied your request. The Plan says the provider in this case is out 
of network. The Plan says that services that you receive out of network are not covered. The Plan also says that 
the claim for September 24, 2019 was received past the 12 month filing limit. 
 
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 rules also 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of 
network are not covered. Additionally, the record shows that the claim for date of service September 24, 2019 
was not received by the Plan until October 2, 2020, more than 12 months after the date of service. 
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the panoramic 
x-ray (D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided from 
September 24, 2019 to November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a naturopathic doctor. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pre-approve a referral to a naturopathic doctor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you recommend the enrollee be 
approved for admission to the LTACH level of care. You also say that a skilled nursing facility is not the 
appropriate level of care at this time. The Plan denied your request. The Plan says the LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. Our reviewer found that there are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Our 
physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the life vest provided on June 15, 2020. 
 
You asked the Plan to pay for the life vest. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the item rendered is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file submitted was largely incomplete. The documentation submitted does 
not include reasoning why this item was denied. The claim in the case file is illegible and unable to be read. In 
addition, there is an authorization letter in the case file that states an automatic external defibrillator would be 
approved from April 15, 2020, to July 15, 2020. We also requested additional information be sent by the 
Plan without response. Since there is no documentation in the case file describing why this item was denied, 
the plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the life vest 
provided on June 15, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) and preventive procedure 
(D1999) provided. 
 
You asked the Plan to pay for the gingival irrigation and preventive procedure. You say that you believe the 
Plan should pay because they referred you to this provider. The Plan denied your request. The Plan says these 
services are not covered 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. The Plan contacted the provider and were advised that the provider is 
not billing you for the preventive procedure (D1999). Therefore, we decided that the Plan does not have to pay 
for the gingival irrigation (D4921) and preventive procedure (D1999) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on August 29, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you disagree with the charges because normally an organization helps you 
pay for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct 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 15% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $25 copayment for specialist visits. 
 
You received a Medicare Part B drug injection on August 29, 2020. The allowed amount is $1,863.53 and 15% 
of that is $279.53. 
 
You received the administration of a Medicare Part B drug on August 29, 2020. Therefore, you are responsible 
to pay the $25 copayment for specialist services.  
 
The total amount you owe is: $304.53.  
 
You have been asked to pay the total amount of $304.53 for a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the physician/practitioner services, including doctors office visits 
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 coinsurance for a Medicare Part B drug 
injection and does not have to waive the copayment for the administration provided on August 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two endosteal implants provided on August 7, 2020. 
 
You asked the Plan to pay for the endosteal implants. You say that you believe these implants should be 
covered. The Plan denied your request. The Plan says these services are not eligible for coverage under the 
medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the two endosteal implants 
provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740), core build up (D2950), and the endodontic 
therapy (D3320). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says that the crown is not listed as a covered service. The Plan says core build up 
is not listed as a covered service. The Plan also says that endodontic therapy is not listed as a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage. We requested the 
documentation, but did not receive it. Without the correct documentation we cannot determine if the Plan made 
the appropriate decision. Therefore, we decided that the Plan has to pre-approve a crown (D2740), core build 
up (D2950), and the endodontic therapy (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays and preventive 
procedure provided on September 23, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and preventive procedure. You say that 
you do not believe you are responsible for these services. 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. The Plan also says that you were advised on September 1, 2020 that 
bitewing x-rays are the only type of covered x-rays. Therefore, we decided that the Plan does not have to pay 
for the complete series of intraoral x-rays and preventive procedure provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns provided on February 17, 2020. 
 
You asked the Plan to pay for the crowns. You say that this procedure was medically necessary. The Plan 
denied your request. The Plan says your dental benefit maximum had been met. 
 
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 Plan offer an annual maximum 
benefit of $1,000. The record shows that you met the annual maximum benefit on February 17, 2020, and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
crowns provided on February 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet nerve neurolysis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not cover services that are not reasonable and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the LCD requires 80% pain relief from each injection to be clearly documented. Additionally, the 
enrollee has other probable pain generators.  Therefore, the request 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet nerve neurolysis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure (CPT Code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says the services are considered experimental and investigational. 
 
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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in this circumstance, therapy change based on data obtained from a 
CardioMEMS device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met, in my opinion, since the device should still be considered 
experimental or investigational. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure (CPT Code(s): 33289 and C2624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart (75571).
You asked the Plan to pre-approve a CT scan of the heart. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found review of the records shows 
no clinical symptoms to suggest coronary artery disease. The CMS criteria for coverage of such a test do not 
consider family history to be a covered indication for screening.
 
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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart (75571).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 11, 2019. 
 
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely 
notification of the enrollee's insurance coverage. The Plan denied your request. The Plan says the claim was 
received past the allowed timeframe. 
 
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 services was not filed until September 10, 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 medical services provided on June 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.