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

We decided that the Plan does not have to pre-approve a partial upper denture (D5213), a partial lower denture
(D5214), crowns (D2740) for teeth # 20, 21, and 22, and core build up for teeth # 20 ,21, and 22.

You asked the Plan to pre-approve the dental services. You say that your mouth is sore from trying to use old
dentures. You say that your previous dentist put in plastic crowns. You also say that you have not used dentures
and have had 2 crowns fall out. The Plan denied your request. The Plan says dentures are covered once every 5
plan years. The Plan says that crowns are covered once every 5 plan years. The Plan also says that the
frequency limits have been exceeded.

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 and the services are listed as covered,
the frequency limits have been exceeded.

Date of Service
CPT Code
Date Plan Paid

10/7/2016
D5214
11/4/2016

5/8/2019
D5213
5/24/2019

4/6/2021
D2740 (# 21, 22)
4/16/2021

4/6/2021
D2950 (# 21, 22)
4/162021

7/31/2020
D2720 (# 20)
8/21/2020

7/31/2020
D2950 (# 20)
8/21/2020

Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213), a partial lower denture (D5214), crowns (D2740) for teeth # 20, 21, and 22, and core build up for teeth # 20 ,21, and 22.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 27, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 23, 2020.

You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). The Plan denied your request. The Plan says the ambulance transport was not medically necessary. The enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 67-year-old male who was short of breath for two months and ambulance services were requested to get a script for oxygen as he does not have a pulmonologist. He was found to be walking without any other complaints, vitals stable, lungs clear. The presenting symptoms of this enrollee do not meet criteria as needing emergency care. The documentation does not support that other means of transportation were contraindicated for this enrollee. The documentation does not support that the enrollee needed expertise or special equipment during transport. The enrollee's vitals were stable. He was not hypoxic or in acute respiratory distress. The ambulance transport was 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at issue in this appeal. 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 services provided by an out-of-network provider on January 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from May 1, 2020, through
May 19, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines of requiring skilled nursing or skilled rehab services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a standby assist level to independent level with functional mobility including gait to 300 feet. 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. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from May 1, 2020, through May 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) scan without contrast provided on February 2, 2021.

You asked the Plan to waive the copayment for an in-network CT scan. You say that you have never paid any cost share for CT scans in the past and would like the insurance to cover this CT scan 100%. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 in network, outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $272.56 copayment for an in-network CT scan. The record shows the Medicare Allowed Amount is $272.56, which is lower than your copayment of $295 per the EOC. An in-network CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 in-network computed tomography (CT) scan without contrast (74176) provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee checks his sugars infrequently and does not frequently adjust insulin. The enrollee uses insulin once daily. The elements of the coverage criteria are not satisfied. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
November 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

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 services at issue in this appeal. 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 services provided by an out-of-network provider on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiofrequency ablation to the sacroiliac joint (64625) performed on September 28, 2020.

You asked the Plan to pay for a radiofrequency ablation to the sacroiliac joint. You say that the requested procedure was a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is experimental/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 pay for a radiofrequency ablation to the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the procedure at issue is considered experimental/investigational because of the wide variation in efficacy. 

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 radiofrequency ablation to the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation to the sacroiliac joint (64625) performed on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this would help the enrollee with daily testing. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Denosumab injection provided on December 9, 2020.

You asked the Plan to waive the coinsurance for a Denosumab injection. You say that this was a shot similar to other shots you have received in the past. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for a Denosumab injection. The allowed amount of the claim is $1,255.47, resulting in a coinsurance obligation of $251.09. The EOC confirms that 20% is the required coinsurance for this service. A Denosumab injection falls within the Medicare Part B prescription drugs 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 Denosumab injection (J0897) provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from the preferred provider.

The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies.

We looked at the file and Medicare rules. The requested Dexcom G6 CGM is not the preferred provider with the Plan. The Plan can approve the Freestyle Libre CGM from the preferred provider. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three surgical extractions, two bone replacement grafts for ridge preservation, and two gum surgeries to be rendered by an OON provider.

You asked the Plan to pre-approve the surgical extractions, bone replacement grafts, and gum surgeries. You say that you need to find a dental surgeon near the area you live in. The Plan denied your request. The Plan says services are only covered for in-network dentists.

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 three surgical extractions, two bone replacement grafts for ridge preservation, and two gum surgeries to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Genvisc injection services.

You asked the Plan to pre-approve the Genvisc injection services. You say that the records provided support the need for Genvisc injections. The Plan denied your request. The Plan says that the records provided do not support that the requested injection services are medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Genvisc injection services. Our reviewer says that the criteria for coverage of the requested injection services have been met. Our physician reviewer found the enrollee has chronic left knee pain. On physical exam, the enrollee has crepitus. X-ray support the diagnosis of Osteoarthritis. He had an oral steroid dose pack. He also had intra-articular steroid injection. There is clear documentation of left knee osteoarthritis and lack of effect of prior therapy. The request for a trial of viscosupplementation is medically reasonable and 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 Genvisc injection services have been met. Therefore, we decided that the Plan has to pre-approve Genvisc injection services.

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 pre-approve additional non-emergency, non-ambulance transportation trips.

You asked the Plan to pre-approve the additional non-emergency, non-ambulance transportation trips. The Plan denied your request. The Plan says the enrollee still has transportation trips (of the 52 one-way trips) available from his benefit. Some available trips are already scheduled, some are pending scheduling, but the enrollee is requesting transportation services in excess of fifty-two trips the health Plan provides him.

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.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency, non-ambulance transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist visit you had on February 9, 2021.

You asked the Plan to waive the co-payment. You say that you shouldn't have to pay the co-payment. The Plan denied your request. The Plan says you are responsible for the co-payment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for each specialist visit.

Review of the file shows that you had specialist office visit on February 9, 2021. You have been asked to pay a $30 co-payment for the visit. The visit falls within the physician services 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 co-payment for the specialist visit you had on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy services (J2405, J0330, J3010, J2704, J2250, J0690, J7120) provided on September 9, 2020, to September 15, 2020.

You asked the Plan to waive the coinsurance for chemotherapy services. You say that you were never advised of this cost-share and never consented for the Plan to charge you for these services. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs including chemotherapy drugs.

You have been asked to pay a 20% coinsurance for chemotherapy services. The allowed amount of the claim is $789.99, resulting in a coinsurance of $158. The EOC confirms that 20% is the correct coinsurance for this service. Chemotherapy services fall within the Medicare Part B prescription drugs 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 chemotherapy services (J2405, J0330, J3010, J2704, J2250, J0690, J7120) provided on September 9, 2020, to September 15, 2020.