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

 
We decided that the Plan does not have to waive the deductible and copayment for cataract surgery provided on 
February 11, 2020. 
 
You asked the Plan to waive the deductible and copayment for cataract surgery. You say that you are on a 
limited income and cannot afford to pay this amount. The Plan denied your request. The Plan says the 
deductible and copayment amounts you are being charged are 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 $1,000 
deductible and $350 copayment for in-network outpatient surgery at an outpatient hospital. At the time this 
claim was processed, $700.83 of the $1,000 deductible had been met. The allowed amount of this claim is 
$2,302.28, resulting in a deductible amount of $299.17 because this amount met the $1,000 total deductible 
amount for 2020. The remaining allowed amount of the claim is $2,003.11, resulting in a copayment of $350. 
Your total cost-sharing obligation is therefore $649.17. 
 
You have been asked to pay $1,000 deductible and $350 copayment for cataract surgery. Cataract surgery 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 deductible and copayment for 
cataract surgery provided on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on March 1, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not aware that they 
were out-of-network. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. An in-network provider and out-of-
network provider has the same copayment amount; therefore, the correct copayment has been applied. 
Ambulance services fall within the ambulance 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 copayment for ambulance services provided by a participating provider on March 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom shaped protective cover, below knee, 
represented by CPT code L5704. 
 
You asked the Plan to pre-approve a custom shaped protective cover. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custom shaped protective cover identified with 
code L5704 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of a custom shaped protective cover have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom shaped protective cover, below knee, represented 
by CPT code L5704.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genomic Sequencing Procedures and Other Molecular 
Multianalyte Assays with CPT code 81455 provided on July 10, 2020. 
 
You asked the Plan to pay for CPT code 81455. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per A56199, CPT code 81455 is considered not medically necessary, 
and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of CPT 
code 81455 have not been met. Therefore, we decided that the Plan does not have to pay for the Genomic 
Sequencing Procedures and Other Molecular Multianalyte Assays with CPT code 81455 provided on July 10, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services (D0140, D0220, D0230, 
D6930) provided on July 6, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for the dental services. You say that this was an emergency situation and 
you needed to go to an OON provider. The Plan denied your request. The Plan says the claim processed 
correctly, and no reimbursement is due. 
 
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.  
 
We looked at the file and Medicare rules. You have been asked to pay the difference between the amount the 
provider billed the Plan and the total cost the Plan approved. When services are received from an OON 
provider, the dentist is allowed to bill the difference between the amount they are charging and the amount the 
Plan is covering. Based on this information, we decided that the Plan's rules for coverage of the dental services 
have been met and the cost share processed correctly. Therefore, we decided that the Plan does not have to 
reimburse you for the dental services (D0140, D0220, D0230, D6930) provided on July 6, 2020 by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on July 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on July 7, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 10, 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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on April 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex procedure spacer device implantation (CPT 
Code 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are not enough scientific studies to show that inserting a device to open the 
narrowed space would be safe and effective for you. 
 
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 items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the device is experimental. More research is needed to show safety and 
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 the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex procedure spacer device implantation (CPT Code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and electronic connection for a power wheelchair (PWC). 
 
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 not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. 
The rules say that an expandable controller with harness and electronic connection are covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is denied by Medicare 
because it does not serve a purpose that is primarily medical in nature. The file does not show that the 
expandable controller with harness and electronic connection are needed, as the enrollee is able to control the 
power options using their own approved switches. 
 
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 power seat elevation system, expandable 
controller with harness, and electronic connection for a power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of the Brain and Spine to be done at a Tertiary 
Care Center. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the notes do not show this service cannot be performed at the community level so this 
request has been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found there is no documentation provided necessitating obtaining the requested imaging studies at the tertiary 
care facility. Ancillary medical requests such as imaging studies may be appropriate for redirection to a 
community-based provider if appropriate access standards and equivalent services can be met. In this case, the 
member has been approved for MRI of the brain and spine within network. The review has determined that the 
requested MRIs are not medically reasonable or necessary at a tertiary care center. 
 
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 the MRI of the Brain and Spine to be done at a Tertiary Care Center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you lost the last pair of dentures that 
was made for you. You also say that you are unable to chew your food, and eating has been very difficult for 
you. The Plan denied your request. The Plan says these services exceed the maximum count allowed per 
period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on 
June 5, 2019, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits 
have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary 
denture (D5110) and complete mandibular denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not refuse to go to the hospital by 
ambulance. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 6, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows you signed a Treatment Refusal. Therefore, we decided that the Plan does not have to pay for 
the ambulance services provided on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that 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 a scheduled total hip replacement. Her medical conditions are stable. There are no medical needs 
requiring an 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 25, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that you would like reconsideration because 
prior authorization is not required for this service. The Plan denied your request. The Plan says utilization of 
network providers is required unless prior authorization is obtained in non-emergent situations. 
 
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 September 25, 
2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation (99254) provided on April 1, 2020. 
 
You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99254 has a stats indicator of I 
which is not valid for Medicare purposes. 
 
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 99254 is not supported in the record. Specifically, per Medicare, CPT code 99254 has a 
status indicator of I. This means that CPT code 99254 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the inpatient consultation have not been met. 
Therefore, we decided that the Plan does not have to pay for the inpatient consultation (99254) provided on 
April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant (D6010) 
for teeth # 6 and 11. 
 
You asked the Plan to pre-approve the dental services. You say that when signing up for benefits, you 
specifically asked about implants. You say that you have a $3,000 voucher towards implants alone. You say 
that you should have never switched plans. You also say that you were misled about information to sign up. 
The Plan denied your request. The Plan says implants are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Customer Handbook specifically states that implants are not 
covered. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an 
endosteal implant (D6010) for teeth # 6 and 11.  
 
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent urinary catheters provided on March 3, 2020 by 
an out of network provider. 
 
You asked the Plan to pay for intermittent urinary catheters (A4352). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the durable medical equipment was 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 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 intermittent urinary catheters provided on March 
3, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - 3/4 cast high noble metal (D2780) provided on 
August 5, 2020. 
 
You asked the Plan to pay for the crown - 3/4 cast high noble metal. You say that this service was medically 
necessary and should be a covered benefit. The Plan denied your request. The Plan says this service is not a 
covered benefit under your benefit package. 
 
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 crown 
- 3/4 cast high noble metal (D2780) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on July 
20, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the Plan information showed this 
provider as being in-network. You also say that the provider told you that they were not in-network. The Plan 
denied your request. The Plan says this service is not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431) provided on July 20, 2020.