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

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 11. 
 
You asked the Plan to pre-approve a crown. You say that the enrollee needs a crown for tooth 11. The Plan 
denied your request. The Plan says there is no clinical evidence to support medical necessity for the requested 
crown. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable and there is pathologic destruction to the tooth by caries or 
trauma and must involve four or more surfaces and at least 50% of the incisal edge. 
 
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 crown. Our reviewer says that criteria 
for coverage of a crown are not met. Our physician reviewer found that the documentation supplied does not 
show that the requested services are necessary.  The x-rays reveal an endodontically treated tooth with an intact crown not showing any defects.  There would be no medical necessity to replace a crown that is intact and not 
subject to any decay processes. Tooth #11 has an existing crown and does not need multi surface restorations. 
There is no noted pathologic destruction to tooth #11 which does have an existing full coverage crown in place 
that does not show any defects or carious lesions around it that would compromise the integrity of the existing 
crown. Given there is no apparent issue with the existing crown, there is no coverage for a replacement crown.  
If this x-ray was taken after the crown was completed, any assessment for need for a crown must be based on a 
pre-treatment x-ray, which is not included in the supplied documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown - porcelain/ceramic (D2740) for tooth 11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2021. 
 
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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found imaging shows fracture retropulsion into 
the spinal canal and that is a contraindication to kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty and vertebroplasty. 
 
You asked the Plan to pre-approve kyphoplasty and vertebroplasty. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty 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 kyphoplasty and vertebroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found criteria for kyphoplasty have not been met. There is retropulsion of b one in the canal and the fracture is not less than 6 
weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty and vertebroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve kyphoplasty and vertebroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure performed 
on November 16, 2021. 
 
You asked the Plan to waive the copayment for the surgical procedure. You say that the procedure should not 
be billed as outpatient surgery. You say that you were informed there would be no charges. 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 a $425 
copayment for surgery or surgical procedures performed at an outpatient hospital facility.   
You have been asked to pay $329.47, which is less than the $425 copayment for the surgical procedure. The 
surgical 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 copayment 
for an outpatient surgical procedure performed on November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental. More research is needed. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteopromotive allograft. 
 
You asked the Plan to pre-approve osteopromotive allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 osteopromotive allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found osteopromotive allograft is experimental in spine surgery. Iliac crest bone graft is the 
gold standard. It is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteopromotive allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteopromotive allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the electrocardiogram (EKG), lab 
services, and urinalysis you received on November 15, 2021. 
 
You asked the Plan to waive the cost sharing for the EKG, lab services, and urinalysis. You say that the EKG 
and blood work were part of your annual physical and you were never charged for this in the past. The Plan 
denied your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that labs and tests you get 
during an annual physical will have separate cost sharing.  The contract says that you must pay a $25 
copayment for outpatient diagnostic procedures and tests and a $15 copayment for lab services.   
You have been asked to pay a $25 copayment for the EKG, and a $15 copayment each for the lab services and 
urinalysis. Because the allowed amounts for the EKG ($16.13) and the urinalysis ($3.48) are less than your 
copayment obligations for those services, you were charged the full allowed amounts for each. 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 sharing for the electrocardiogram (EKG), lab services, and urinalysis you 
received on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported removable lower 
denture for edentulous arch (D6111). 
 
You asked the Plan to pre-approve an implant/abutment supported removable lower denture for edentulous 
arch. You say that the services are necessary. The Plan denied your request. The Plan says the requested 
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 an 
implant/abutment supported removable lower denture for edentulous arch (D6111).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air fluidized bed (E0194) provided on January 24, 2021, 
through August 24, 2021. 
 
You asked the Plan to pay for the air fluidized bed. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the rental cap has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors continue to pay rental fees not to 
exceed a period of continuous use of 13 months and ownership of the equipment passes to the beneficiary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air fluidized bed have not been met. Specifically, the documentation supports that this 
equipment was paid for from 2019 through 2020. The record indicates that the rental cap has been met. Therefore, we decided that the Plan does not have to pay for the air fluidized bed (E0194) provided on January 
24, 2021, through August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this service should be reprocessed based on 
the medical records. The Plan denied your request. The Plan says this claim has processed correctly as the 
claim has not been billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder heart monitoring device. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this monitor is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is no medical necessity for the 
requested heart monitor. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that at issue is whether the requested authorization for placement of an 
implantable loop recorder (ILR) is medically appropriate and necessary. Repeated 7-day ambulatory 
electrocardiogram event monitoring has been negative and there have been no recurrences of symptoms. There 
is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this patients clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder heart monitoring device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on August 24, 
2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you already had your follow 
up with the gastroenterologist, so you called and cancelled your appointment with the Oncologist, but they 
called you anyways. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist.  
 You have been asked to pay a $40 copayment for the telehealth visit. A telehealth visit falls within the 
Physician/Practitioner services, including doctors 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 the telehealth visit provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan on July 26, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you cannot afford the copayment 
because you only receive social security. The Plan denied your request. The Plan says the copayment is 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 $150 
copayment for in-network Medicare-covered diagnostic radiology services.  
  You have been asked to pay $111.26, which is less than the standard $150 copayment for CT scan. The CT 
scan 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 CT scan July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on November 24, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from the enrollee's primary care physician. The prior surgery done had a 90-day global 
period which ended on May 13, 2021, and no new authorization was made for this visit on November 24, 2021. 
Also, the service rendered was not urgent or emergent. 
 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 a specialist office visit provided on November 24, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an allergy specialist office service provided 
on December 20, 2021. 
 
You asked the Plan to waive the copayment for an allergy specialist office service. You say that you were 
previously told that this is a 100% covered service. 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 a $35 
copayment for a specialist visit.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $10.92, which is less than the $35 copayment for an allergy specialist office service. An 
allergy specialist office service falls within the Physician/Practitioner Services, Including Doctors 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 an allergy specialist office 
service provided on December 20, 2021.