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

 
We decided that the Plan has to pay for the dental services you received on June 30, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that the benefit 
maximum was reached. 
 
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 says that the maximum benefit has been reached for comprehensive 
dental services. The Plan covers up to a maximum of $3,900 every year for comprehensive dental services. The 
documentation submitted by the Plan shows that the plan paid $1,935 toward the dental services you received 
on May 17, 2017. The Plan has not submitted any documentation of dental services covered in 2020 exceeding 
the benefit limit. Without supporting documentation, the Plan?s denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the dental services you received on June 30, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 17, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should not be responsible for 
the copayment. You say you had to repeat the Abdominal Aortic Aneurysm (AAA) screening because the 
results were unclear on your first AAA screening on November 15. 2019. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount and that the provider has written off the 
copayment amount and is not billing you for the service. 
 
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 $160 
copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $112.79 copayment, which is less than the standard copayment amount, for the 
ultrasound. The 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 the ultrasound provided on February 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis, bacterial urine culture, and outpatient hospital
clinic visit provided on December 4, 2019.
You asked the Plan to pay for the urinalysis, bacterial urine culture, and outpatient hospital clinic visit. You say
that the payment was retracted for other coverage with hospice, but the Plan is the primary. The Plan denied
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered
services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the urinalysis, bacterial urine culture, and outpatient hospital
clinic visit provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two extractions, additional intraoral periapical x-ray, first 
intraoral periapical x-ray, and problem focused limited oral evaluation provided on April 21, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the extractions, intraoral periapical x-rays, and problem focused limited oral 
evaluation. You say that you have a $200 allowance toward tooth extractions, but it has been denied. The Plan 
denied your request. The Plan says the treating provider is OON. 
 
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 pay for the two 
extractions, additional intraoral periapical x-ray, first intraoral periapical x-ray, and problem focused limited 
oral evaluation provided on April 21, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reduction mammoplasty.
You asked the Plan to pre-approve a reduction mammoplasty. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that reduction mammoplasty is covered when the above LCD criteria are met. 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 reduction mammoplasty. Our reviewer says that a reduction mammoplasty is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that there is insufficient documentation that the enrollee has a functional impairment that would likely improve or resolve with an additional breast reduction. The medical documentation did not provide clear evidence of functional impairment related to her previous hematoma or current breast findings. In addition, there is insufficient documentation that the enrollee has clear significant deformity/asymmetry related to her postoperative complication that rise to reconstructive principles. The findings documented were noted to be 'slight' and no photographs were provided for review.
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 reduction mammoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a reduction mammoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic facet injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic facet injections are covered for the above 
indications. 
 
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 injections. Our reviewer says that 
the requested injections are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has multiple other pain generators and facet blocks are not indicated at the level of prior surgery. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve diagnostic facet injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy provided on January 3, 
2020. 
 
You asked the Plan to waive the copayment for a nasal endoscopy. You say that you disagree with 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 a $285 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay the total amount of $112.53, which is less than the $285 copayment for a nasal 
endoscopy. A nasal endoscopy falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 a nasal endoscopy provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray and scaling provided on 
October 31, 2019. 
 
You asked the Plan to pay for the intraoral periapical x-ray and scaling. You say that the services were a 
necessary part of the routine cleaning. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 
intraoral periapical x-ray and scaling provided on October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 19, 2020
to January 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not meet criteria for skilled services during this time, as the enrollee was terminated from hospice status on
January 7, 2020 and remained on traditional Medicare until January 31, 2020. The enrollee became eligible for
the Medicare advantage plan on February 1, 2020.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on January 7, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing
services provided from January 19, 2020 to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these services. 
 
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 an office visit provided on January 7, 2020 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve the mattress. You say that this is a high risk patient for developing sacral or gluteal ulcers and the first step in medicine is prevention and you request reconsideration. The Plan denied your request. The Plan says the records provided do not support medical necessity of the requested service.
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 mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found No medical records have been submitted for review. Based on the appeal letter, it sounds as though the enrollee does not currently have any ulcers. Therefore, the documentation does not support that he requested air mattress is medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve dynamic adjustable ankle extension/flexion device (E1815).
You asked the Plan to pre-approve the orthosis. You say that you need the correct decision to be made about the medical necessity of a Dynasplint system for your left Achilles tendon. The Plan denied your request. The Plan says that mechanical stretching devices re not medically necessary for the ankle.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the orthosis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found after careful review of enclosed information, it appears that this enrollee does not necessarily need stabilization, but does need stretching of the Achilles tendon. The enrollee's Achilles tendon is noted to be tight and contracted which is inhibiting normal ambulation. This is a common sequel after Achilles surgery. The enrollee most definitely has the potential to benefit functionally with the use of the Dynasplint stretching device. This device uses a mechanism to apply gentle force to a joint to improve and increase joint ROM. Proper ankle joint ROM is necessary for correct and comfortable ambulation. In this particular case, this enrollee is noted to have a tight Achilles tendon due to prior surgery. The Dynasplint device, with its specialized mechanism for stretching, will provide ankle joint ROM improvement for this enrollee. 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 orthosis have been met. Therefore, we decided that the Plan has to pre-approve dynamic adjustable ankle extension/flexion device (E1815).
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve block and radiofrequency ablation (RFA) of the 
genicular nerves. 
 
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is an experimental/investigational procedure that is the subject of on-going clinical trials. 
 
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 a nerve block and radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0820). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the enrollee is legally blind and cannot safely operate 
the power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a beneficiary must have the physical capabilities 
to safely operate the power wheelchair that is provided.  
 
We looked at the file and Medicare rules. The evaluation provided in the records shows the enrollee is legally 
blind and could not safely operate the power wheelchair. Based on this information, we decided that Medicare 
rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (K0820).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis services coded 88377 provided on 
April 29, 2019. 
 
You asked the Plan to pay for the morphometric analysis services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says separate payment is not allowed. 
 
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, we have confirmed that code 88377 
for the morphometric analysis service has a bundled relationship with code 81445 and cannot be paid as billed. 
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services 
coded 88377 provided on April 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 21, 2020 to 
April 22, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs could have been met on an 
outpatient basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not have complex treatment needs which might warrant a two-
midnight stay in the hospital. The enrollee required insulin adjustments, home medication adjustments, and 
additional IV fluids and basic monitoring, which could have been completed on an observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided April 21, 2020 to April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 2, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that the physician you saw could not help you and you feel that the visit was a waste of your time and a risk due to COVID-19. 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 a $35 copayment for a specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 waive the copayment for a specialist visit provided on April 2, 2020.
We note your complaint that the physician could not help you. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.