Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The record indicates 
that the enrollee is scheduled for a total knee arthroplasty. The record does not document that the treating 
physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be 
admitted for observation. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures. 
 
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 a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
complete dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an eye injection provided on January 4, 
2022, and January 12, 2022. 
 
You asked the Plan to waive the cost share for an injection. You say that the charges are much higher than they 
were with your previous insurance company. You also say that you cannot afford these payments. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for Part B drugs. The Plan contract also say that enrollees must pay a $400 copayment for outpatient hospital surgery services. 
 
You have been asked to pay $378.19, which is 20% coinsurance of the allowed amount for an injection on 
January 4, 2022 ($1,890.96 allowed amount x 20% coinsurance = $378.19). An injection falls within the 
Medicare Part B Prescription Drugs benefit category.  
 
You have been asked to pay the allowed amount of $343.43, which is less than the $400 copayment for each 
eye injection procedure on January 4, 2022, and January 12, 2022. You have been asked to pay a total of 
$1,065.05 ($378.19 coinsurance + $343.43 copayment + $343.43 copayment = $1,065.05). An eye injection 
procedure 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 cost share for an eye 
injection provided on January 4, 2022, and January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the out-of-network provider was the quickest 
way for you to get some relief from your pain. The Plan denied your request. The Plan says rules for out-of-
network care have not been met. 
 
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 had network providers 
available who could have provided 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 chiropractic services provided on February 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vancocin capsule. 
 
You asked the Plan to pre-approve Vancocin. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
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 treatment with Vancocin 
capsule.  
 Benefits for Vancocin 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on June 19, 2020. 
 
You asked the Plan to pay for the laboratory test. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 coronavirus test (U0003) provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cancelled appointment (D9987) from January 26, 2022. 
 
You asked the Plan to pay for the cancelled appointment. You say that you would like to fix your two front 
teeth which were altered by inferior dental mistakes. You also say that your new dentist has informed you that 
crowns can be placed to cover the damaged teeth. The Plan denied your request. The Plan says cancelled 
appointment fees are not specifically listed in the Evidence of Coverage, and 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 Plans 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 
cancelled appointment (D9987) from January 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS 3D biopsy coded as 88361, 88312, 88305, 88104. 
 
You asked the Plan to pay for the WATS 3D biopsy. You say that please review and respond with coverage of 
your claim for the performance of WATS 3D tissue analysis which is not a standard of care when ordered 
according to ASGE guidelines and deemed medically necessary for this enrollee. The Plan denied your request. 
The Plan says that the testing is not medically necessary. 
 
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 pay for the WATS 3D biopsy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of wide area trans-epithelial sampling (WATS 3D) is supported in guidelines by the 
American Society of Gastrointestinal Endoscopy for patients with known or suspected Barrett's esophagus. The 
clinical documentation in the case file supports that the enrollee in this case has known Barrett's esophagus. 
WATS 3D has been shown to increase Barrett's esophagus and dysplasia detection when used alongside 
forceps biopsy in patients undergoing esophageal lesion screening or surveillance. 
 
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 WATS 3D biopsy have been met. Therefore, we decided that the Plan has to 
pay for the WATS 3D biopsy coded as 88361, 88312, 88305, 88104.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 support mattress. 
 
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 medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that a Group 2 support mattress is covered when 
specific 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found you have multiple group two pressure 
ulcers and have failed the use of an appropriate group one support surface. The documentation does not show 
that you have multiple stage three or four pressure ulcers on the trunk or pelvis or a myocutaneous flap 
(compound flaps of skin and muscle) or skin graft for a pressure ulcer on the trunk or pelvis in the past 60 days. 
The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 Group 2 support mattress.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DynaCad for magnetic resonance imaging (MRI) 
rendered on November 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and Medicare rules. There is no documentation to support that the DynaCad was medically necessary. 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 pay for the DynaCad for magnetic 
resonance imaging (MRI) rendered on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), and pontic (D6245) provided on 
January 17, 2022, by an out of network dentist. 
 
You asked the Plan to pay for the core build up and pontic. You say that your dental benefit should cover 1 
crown and 1 core build up. The Plan denied your request. The Plan says core build up is not a covered service. 
The Plan also says that the annual maximum benefit has been reached. 
 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, the core build up are not among those 
covered under this benefit. Additionally, the record shows that the annual maximum benefit of $2,000 has been 
exhausted with the reprocessing of this claim. Therefore, we decided that the Plan does not have to pay for the 
core build up (D2950), and pontic (D6245) provided on January 17, 2022, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 27, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was your understanding that you had $3,000 in 
dental coverage. You say that this is your first year with dental insurance. You also say that you cannot afford 
to pay this bill. The Plan denied your request. The Plan says the frequency limit has been exceeded. 
 
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 and a comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on January 10, 2022. 
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110), complete 
mandibular denture (D5120), and buccal/labial frenectomy (D7961) provided on December 8, 2021. 
 
You asked the Plan to pay for the complete dentures and buccal/labial frenectomy. You say that you would like 
to be reimbursed for these services. The Plan denied your request. The Plan says these procedures are not 
covered under your dental 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 
complete maxillary denture (D5110), complete mandibular denture (D5120), and buccal/labial frenectomy 
(D7961) provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zostavax administration (90471) provided on January 5, 
2022. 
 
You asked the Plan to pay for the Zostavax administration. You say that this vaccine was billed under your 
medical insurance rather than your pharmaceutical insurance. You also say that this vaccine should be covered 
in full if it is billed correctly. The Plan denied your request. The Plan says the administration of a vaccine is not 
covered when the vaccine itself is not covered by your healthcare plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zostavax 
administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Zostavax 
administration. Therefore, we decided that the Plan does not have to pay for the Zostavax administration 
(90471) provided on January 5, 2022.  
 
 
 
 
 
 
 
  
Benefits for the Zostavax administration may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to provide treatment safely and 
effectively, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight (8) additional physical therapy (PT) visits (97164).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), adjunctive pre-
diagnostic test (D0431), topical application of fluoride varnish (D1206), crown (D2740), core buildup, 
including any pins when required (D2950), and 6 localized deliveries of antimicrobial agents (D4381 x6) 
provided from August 31, 2021, to September 20, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, adjunctive pre-diagnostic test, topical 
application of fluoride varnish, crown, core buildup, and localized deliveries of antimicrobial agents. You say 
that until December 30 you were not advised that the treating provider was OON. The Plan denied your 
request. The Plan says these services are not covered expenses under your dental plan. 
 
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, 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 first 
intraoral periapical x-ray (D0220), adjunctive pre-diagnostic test (D0431), topical application of fluoride 
varnish (D1206), crown (D2740), core buildup, including any pins when required (D2950), and 6 localized 
deliveries of antimicrobial agents (D4381 x6) provided from August 31, 2021, to September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve torus removal from the jaw. 
 
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. 
 
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, 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 torus 
removal from the jaw.