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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 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 medical services provided to the enrollee by an out-of-network provider 
on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 22, 2020 to August 3, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that you did not realize the Plan would not cover this 
provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 medical services provided on June 22, 2020 to 
August 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 8 extractions (D7210) and the inhalation of nitrous oxide (D9230) provided on July 23, 2020.You asked the Plan to pay forthe dental services. You say that you are on a limited budget. You say that you were put on in house financing. You say that due to Covid-19 these payments are almost impossible for you to pay. the dentures you received were very much needed. You say thatThe Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that dental services that you receive out of network 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, dental services that you receive out of network are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe 8 extractions (D7210) and the inhalation of nitrous oxide (D9230) provided on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this IRF admission is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform 15 hours per week of rehabilitative services with 
regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled 
nursing facility. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and excision of 
benign lesion provided on September 18, 2020, and October 2, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and excision of benign lesion. You 
say that you believe these services should be covered with a $65.00 copay. 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. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation and excision of benign lesion provided on September 18, 2020, and 
October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Power module for use with electric or 
electric/pneumatic ventricular assist device, replacement only (Q0479) provided July 13, 2020. 
 
You asked the Plan to waive the copayment for the orthotic device. You say that you don't believe you should 
pay this. This unit was defective and they replaced with a new one. They should cover the cost. The Plan 
denied your request. The Plan says the claim was processed and the correct copayment applied per the 
Evidence of Coverage. 
 
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 each prosthetic or orthotic device, including replacement or repairs of such devices and related 
supplies.  
 
You have been asked to pay $1,577.52 (amount billed $10,800, allowed amount $7181.20, paid amount 
$5,722.96.) for the orthotic device. The orthotic device falls within the Prosthetic Devices and Related 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 Power module for use with 
electric or electric/pneumatic ventricular assist device, replacement only (Q0479) provided July 13, 2020.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee is 
currently undergoing treatment at an acute care hospital (ACH) for sepsis related to pneumonia and chronic 
wounds. She is on a ventilator and not tolerating weaning. There is no evidence that the enrollee requires 
services that are not currently available at the ACH. As LTACHs and ACHs are licensed to provide the same 
level of care, there is no advantage in transferring the enrollee to the LTACH. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says the enrollee does not have complex nursing and medical management needs 
requiring an intensive inpatient hospital setting. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for treatment of a suprasellar mass. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does 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. There is not a 
reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (X-Ray) 
(D0220) provided on August 18, 2020. 
 
You asked the Plan to pay for periapical X-Ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says you have exhausted your benefit frequency for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, the records show you were reimbursed for this same 
service on March 10, 2020. This means you have already exhausted your Plan benefit frequency making this a 
non-covered service. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first 
radiographic image (X-Ray) (D0220) provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on September 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that when you signed up for this plan, you were 
advised that you could continue to see the providers that you have been seeing. You say that the services you 
received from this provider last year were paid. You also say that you would like your visits on September 2, 
2020 and September 23, 2020 to be paid as well. The Plan denied your request. The Plan says the provider in 
this case is out of network. The Plan also says that your supplemental dental coverage only provides coverage 
for services rendered by an in-network dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 2, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of 10 additional teeth, periodontal scaling 
and root planing, a porcelain crown, and upper and lower partial dentures. 
 
You asked the Plan to pre-approve the requested dental services. You say that you feel that this should be 
covered. The Plan denied your request. The Plan says you have exhausted your benefit for extractions, and the 
other requested services are not covered by your 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, and only one extraction can be covered per year. Therefore, we 
decided that the Plan does not have to pre-approve the extraction of 10 additional teeth, periodontal scaling and 
root planing, a porcelain crown, and upper and lower partial dentures.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira pen kit. 
 
You asked the Plan to pre-approve the Humira pen kit. You say that you need this medication due to 
autoimmune disease. The Plan denied your request. The Plan says this medication does not fall under your Part 
B benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Humira pen kit.  
 
Benefits for the Humira pen kit may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The provider in question is a licensed professional counselor. This 
type of provider is not eligible to enrollee in the Medicare program. Payment cannot be made to a provider who 
is not enrolled in the Medicare program. 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 the 
services provided on August 24, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services (A0427 SH and A0425 SH) provided on 
August 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this 
claim was billed with the appropriate modifier. The Plan denied your request. The Plan says that this code does 
not have an ambulance origin and destination modifier or appropriate exception modifier appended. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided. 
 
We find that CPT codes A0427 SH and A0425 SH are supported in the record. Specifically, this claim was 
billed with modifier SH, which is an appropriate origin and destination modifier. Based on this information, we 
decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that 
the Plan has to pay for the ambulance services (A0427 SH and A0425 SH) provided on August 18, 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 pre-approve a mouth guard for teeth grinding (D9944). 
 
You asked the Plan to pre-approve the mouth guard. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 a 
mouth guard for teeth grinding (D9944).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rexulti.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) rendered on July 
22, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a PCD that provides intermittent limb compression for 
the purpose of prevention of venous thromboembolism (E0676) is a preventive service and is non-covered. 
 
We looked at the file and Medicare rules. The provider submitted a claim for a PCD coded E0676. This service 
is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device (PCD) rendered on July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. 
 
You asked the Plan to pre-approve skilled nursing services. You say that the records provided support the need 
for SNF care. The Plan denied your request. The Plan says admission to a SNF is not medically necessary. 
 
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 skilled nursing services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found while the enrollee may have 
skilled nursing needs, the enrollee does not require skilled nursing services or therapy on a daily 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 skilled nursing services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound guidance provided on August 
31, 2020. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you should have been charged $0 for 
this service. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct. The Plan also says that they have reduced the copayment amount for this service from $35 to $30. 
 
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 $30 
copayment for in-network ultrasound.  
 
You have been asked to pay $30 copayment for ultrasound. Ultrasound 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 ultrasound guidance provided on August 31, 2020.