Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on 
August 5, 2020. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received an outpatient hospital clinic visit on the date of service at issue 
in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for all other Medicare-covered outpatient hospital services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient 
clinic visit on August 5, 2020. You have been asked to pay a $20 copayment for the outpatient clinic visit. The 
outpatient clinic visit falls within the Outpatient hospital 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 the outpatient clinic visit provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hematopoietic stem cell trnsplantation (HSCT) (38240). 
 
You asked the Plan to pre-approve HSCT. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that allogeneic HSCT for sickle cell disease (SCD) is 
covered by Medicare only for beneficiaries with severe, symptomatic SCD who participate in an approved 
prospective clinical study. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee is enrolled in a 
prospective clinical study. Based on this information, we decided that Medicare rules for coverage of HSCT 
have not been met. Therefore, we decided that the Plan does not have to pre-approve hematopoietic stem cell 
trnsplantation (HSCT) (38240).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 10, 2020 to 
July 29, 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 need skilled medical care or skilled nursing care during this time. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from July 10, 2020, to July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Voriconazole 200mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the 
enrollee as she was recently treated in the hospital for respiratory failure and pulmonary aspergillosis. The Plan 
denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Voriconazole 200mg 
tablet medication.  
 
Benefits for this medication 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 pre-approve home International Normalized Ratio (INR) testing. 
 
You asked the Plan to pre-approve the requested services. You say that you have heart problems, and need 
testing every two weeks. The Plan denied your request. The Plan says the medical records do not show the 
services are medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that home PT/INR monitoring is only covered under 
certain medical indications.  
 
The file shows that a 12-month supply of testing materials were requested. The Plan has agreed to pre-approve 
a 3-month supply. 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 additional 
requested services. Our physician reviewer found that the in this case, there is no current signed order received. 
The last order is dated April 16, 2018. The review has determined that additional supplies for INR testing are 
medically reasonable or necessary at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home International Normalized Ratio (INR) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedence spectroscopy. 
 
You asked the Plan to pre-approve bioimpedence spectroscopy. You say that Medicare covers this test and its 
efficacy has been established by medical studies. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the clinical utility of this testing has not been established. 
 
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 bioimpedence spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found guidelines state that bioimpedence spectroscopy can be incorporated for 
breast cancer patients that have locoregional and system therapy, but the record is devoid of axillary node 
sampling. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedence spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedence spectroscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down positioning table provided on July 14, 2020. 
 
You asked the Plan to pay for the face-down positioning table. You say that the face-down positioning table 
was necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request is not a 
covered benefit because Medicare considers it a precautionary device. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
   
We reviewed your records and they show that you underwent eye surgery. The record sent by your provider 
indicates that you underwent eye surgery and your provider recommended this device as a precaution to 
prevent complications following your surgery. CMS confirmed that these devices are statutorily noncovered 
because they do not fall within a Medicare benefit category. These types of devices are considered 
"precautionary devices" and also can be used for purposes other than the treatment of an illness or injury. The 
denial is a coverage denial, not a medical necessity denial. Therefore, we decided that the Plan does not have to 
pay for the face-down positioning table provided on July 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 6, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the physicians are seeing the 
enrollees in a contracted home. You also say that the facility of care obtained prior authorization for your 
providers to treat the enrollee. The Plan denied your request. The Plan says this service was rendered by a non-
contracted provider. The Plan also says there was not a valid authorization in the system for this provider. 
 
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 
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 subsequent nursing facility care provided on 
August 6, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre sensors and reader for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there was no documentation that the preferred product on the formulary (Dexcom) 
would not be as effective as the requested product. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found given the age and challenges of a chronically ill patient with a need for frequent acute monitoring, the 
ability to test for blood sugar accurately is very important. The provider has documented the challenges with 
the new Dexcom system for monitoring effectively. There are limitations with some patients based on age and 
disease state to adapt to alternative means of therapy. It is reasonable and necessary to use the Libre supplies. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a Freestyle Libre sensors and reader for the enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery services received on 
August 3, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you did not know it would apply this 
high of a copayment. The Plan denied your request. The Plan says the copayment was applied correctly 
according to your benefits and the services rendered. 
 
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 $300 
copayment for outpatient surgery.  
 
You have been asked to pay $96.55 for the services. The allowed amount of $96.55 was less than the typical 
$300 copayment for outpatient surgery, so you only owe the lower amount. the services falls within the 
outpatient surgery 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 outpatient surgery 
services received on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on August 28, 
2020. 
 
You asked the Plan to pay for this service. You say that you were not aware that your doctor was not in 
network. The Plan denied your request. The Plan says you did not have prior authorization for out of network 
care. 
 
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 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 out of network physician 
services provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you were advised by a plan representative that 
dentures were covered. You say that you have been using a broken denture for 2 years now. You also say that 
you need a new denture in order to be able to eat and live normally. The Plan denied your request. The Plan 
says partial dentures are not listed as a covered 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. Therefore, we decided that the Plan does not have to pre-approve a 
lower partial denture (D5214).  
 
Your complaint about being misinformed 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records to support 
medical necessity. 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 August 10, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for emergency room services provided 
on July 4, 2020. 
 
You asked the Plan to waive this copayment. You say that you only returned for help with a catheter bag and 
should not have to pay this copayment. The Plan denied your request. The Plan says this copayment is a 
contractual obligation. 
 
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 $90 
copayment for emergency room services. 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 charged for emergency room 
services provided on July 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on August 
15, 2020. 
 
You asked the Plan to pay for the dental service. You say that you needed the gas for the procedure that you 
had done. You say that you had to borrow money to pay for the gas out of pocket. You also say that you feel 
that the gas should be added to your coverage. The Plan denied your request. The Plan says the inhalation of 
nitrous oxide is not listed as a covered 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. Therefore, we decided that the Plan does not have to pay for the 
inhalation of nitrous oxide (D9230) provided on August 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 15, 2019 and June 
11, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in a skilled nursing 
facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
May 15, 2019 and June 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the brain and cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an approval for these studies in the system, and the approval has not been used 
yet. 
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the records do not show 
any evidence of neruologic deficit. The physical exam is normal. There is no recent trial and failure of PT for 
neck pain. More conservative measures for headaches should be tried. There are no red flags for MRI at this 
time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the brain and cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair lift and scooter rendered on June 6, 2020 and 
June 22, 2020. 
 
You asked the Plan to pay for these services. You say that you have a hard time getting around. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare does not 
cover these items. Therefore, we decided that the Plan does not have to pay for the wheelchair lift and scooter 
rendered on June 6, 2020 and June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral evaluation (D0120) and prophylaxis (D1110) 
provided on September 8, 2020. 
 
You asked the Plan to pay for an oral evaluation and prophylaxis. You say that this should be covered. The 
Plan denied your request. The Plan says this exceeds the frequency limitation for these 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 
covered only once a year under this benefit. The record shows that you previously received these services on 
March 3, 2020. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0120) and 
prophylaxis (D1110) provided on September 8, 2020.