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

 
We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), and a pulp cap 
(D3120). 
 
You asked the Plan to pre-approve the dental services. You say that the initial paperwork that you received 
does not explain why the services are not covered. You say that the crown on tooth # 3 was placed more than 
10 years ago. You say that your dentist recommends that your broken teeth be covered with crown. The Plan 
denied your request. The Plan says the crown is not listed as a covered service. The Plan says core build up is 
not listed as a covered service. The Plan says the pulp cap is not listed as a covered service either. The Plan 
also says any services not listed 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 pre-approve a 
crown (D2740), core build up (D2950), and a pulp cap (D3120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on June 16, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that please see attached medical 
records. Please review and reconsider claim for payment based medical necessity. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 outpatient hospital services provided on June 
16, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial denture purchased on June 3. 2020. 
 
You asked the Plan to pay for a partial denture. You say that the Plan should pay for this partial. The Plan 
denied your request. The Plan says this is not a covered dental benefit. 
 
Medicare generally does not cover dental services. The Plan contract states that dentures are not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for a partial denture purchased on June 3. 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology procedures provided 
December 28, 2019. 
 
You asked the Plan to pay for intraoperative neurophysiology procedures. You say that due to the fact that your 
services meet the medical necessity guidelines you are requesting  reconsideration of the initial denial for 
payment due for the services rendered. The Plan denied your request. The Plan says invalid procedure code for 
this service. 
 
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 95941 is intraoperative neurophysiology procedures. 
 
We find that CPT code 95941 is not supported in the medical record. Specifically, 95941 was billed with a 
status code of "I". Medicare guidance says status code "I= Not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of intraoperative neurophysiology procedures have not been met. Therefore, we 
decided that the Plan does not have to pay for intraoperative neurophysiology procedures provided December 
28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Methotrexate 2.5 mg tablet.You asked the Plan to pre-approveMethotrexate. You say that Methotrexate is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the drug you are requesting is a self-administered drug and filled by your pharmacy benefit.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-approvethe Methotrexate 2.5 mg tablet.Benefits for Methotrexatemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 25, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network 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 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 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 physician's services provided on December 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on September 20, 
2019 and November 27, 2019. 
 
You asked the Plan to reduce the copayment for the office visits. You say that you were seen by the nurse 
practitioner not the doctor. You say that you shouldn't have been billed the doctor rate. The Plan denied your 
request. The Plan says the copayments applied 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 $50 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician?s assistant or other non-physician health care professionals in a specialist?s office (as 
permitted under Medicare rules).  
 
You have been asked to pay a total of $99.63 for the office visits.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
September 20, 2019 Office Visit $73.28 $50 $50 
November 27, 2019 Office Visit $49.63 $50 $49.63 
TOTAL:    $99.63 
 
  
 
 
The office visits fall within the "Physician/Practitioner Services, Including Doctor?s 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 reduce the copayment for the office visit provided on September 20, 
2019 and November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic services provided to the enrollee from May 21, 
2020 to May 29, 2020 and billed under codes B4185, B4189, B4220 and B4224. 
 
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 there is not a sufficient physician order for the services provided. 
 
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 physician order. 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 orthopedic services provided to the enrollee from May 21, 2020 
to May 29, 2020 and billed under codes B4185, B4189, B4220 and B4224.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP supplies provided on April 30, 2020. 
 
You asked the Plan to pay for the CPAP supplies. The Plan denied your request. The Plan says prior 
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 did not pre-approve the 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for CPAP supplies provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 30, 2020. 
 
You asked the Plan to pay for the podiatry services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
podiatry services. 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 podiatry services provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on April 16, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says there is no commensurate note in the medical record on or around 
that date as to why the brace was being ordered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. The request is not medically 
necessary because the records do not support the need or justification for the brace. Therefore, we decided that 
the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpreventative vaccines provided to the enrollee on July 9, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says preventativevaccines are not covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this service. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to this service.Therefore, we decided that the Plan does not have to pay forpreventative vaccines provided to the enrollee on July 9, 2020.Benefits for this servicemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged physician services (99356) provided December 
10, 2019. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says documentation does not support the services 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. 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the record shows that 75 
minutes were spent on this service. The base code provides for 70 minutes. The prolonged service code is for 
30-74 minutes. The record shows only 5 additional minutes spent on this service. 30-74 minutes is not 
supported. Based on this information, we decided that Medicare rules for coverage of the physician services 
have not been met. Therefore, we decided that the Plan does not have to pay for prolonged physician services 
(99356) provided December 10, 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 enrollee needs a lot of oxygen. The 
Plan denied your request. The Plan says the enrollee has not completed the full course of care in the hospital. 
 
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 physician 
reviewer found that the enrollee presented to the acute hospital with breathing problems and low blood oxygen 
levels. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where she is currently receiving care. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on March 6, 2020. 
 
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network 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 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 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 ophthalmological services provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that the dentist informed you that your 
teeth were in good condition for a removable prosthetic. The Plan denied your request. The Plan says that the 
records show that your teeth may be in poor condition and the treatment may not last until it can be replaced. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the lower 
partial denture when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the lower partial denture. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found that you have five remaining 
mandibular teeth with adequate bone support to support a removable partial denture. Our reviewer says that 
that a prosthesis is reasonable and necessary for adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the lower partial denture have been met. Therefore, we decided that the Plan has 
to pre-approve the lower partial denture.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide transportation, over 50 miles one-way, to your medical 
appointments. 
 
You asked the Plan to provide additional mileage exceeding your routine transportation benefit. You say that 
you need transportation to and from your medical appointments. The Plan denied your request. The Plan says 
the request is exceeding your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation of 48 one-way trips and each one-way trip must not exceed 50 
miles.  
 
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 provide transportation, over 50 miles one-way, to your medical appointments.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lorazepam 1 mg tablet. 
 
You asked the Plan to pre-approve Lorazepam. You say that the requested drug is medically necessary to treat 
the enrollee's condition The Plan denied your request. The Plan says this medication does not fall under 
Medicare Part B coverage. 
 
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 the Lorazepam 1 mg tablet.  
 
Benefits for Lorazepam 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pulmonary function test you had at an 
outpatient hospital facility on May 6, 2020. 
 
You asked the Plan to waive the coinsurance for the pulmonary function test. You say that your doctor ordered 
these tests and the hospital was in-network, so you don't understand why you are getting this bill. The Plan 
denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for diagnostic procedures and tests.  
 
You have been asked to pay 20% coinsurance for the pulmonary function test. The pulmonary function test 
falls within the diagnostic procedures and tests 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 the pulmonary function test you had at an outpatient hospital facility on May 6, 2020.