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

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #4. 
 
You asked the Plan to pre-approve the dental service. You say that you are having a root canal on the tooth and 
need to cover it. The Plan denied your request. The Plan says the x-rays do not show the enrollee has a cavity 
under the old cap. 
 
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 the dental 
service when the services are medically necessary and reasonable.  
 
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 dental service. Our reviewer says 
that the crown for tooth #4 is not medically necessary. Our physician reviewer found that the documentation 
indicates that tooth #4 has a crown in place that appears adequate. There was no indication as to why this 
crown needs replacement. 
 
  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 the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) for tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered; however, the Plan 
has a special supplemental benefit from the chronically ill (SSBCI).  
 
We looked at the file and the Plans rules. The file shows that you do not meet all of the coverage criteria for 
the Plans SSBCI benefit. Based on this information, we decided that the Plans rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
October 17, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that the provider tried to put 
drops in your eyes, but you left and said no. You also say when you left, they told you the copayment was $15 
and that was it. The Plan denied your request. The Plan says this cost sharing was charged 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 Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye.  
 
 
  You have been asked to pay $37.81, which is less than the $40 copayment for a specialist office visit. This 
item/service falls within the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye 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 reduce the copayment for a specialist office 
visit provided on October 17, 2022.  
 
Your complaint about the potentially poor professional service from the provider 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: Imaging
Decision: Unfavorable

 
 
We decided that the Plan does not have to reduce the copayment for a SPECT scan provided on July 5, 2022. 
 
You asked the Plan to reduce the copayment for a SPECT scan. You say that you cannot afford to pay this, and 
you were told your copayment would only be $35. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $295 
copayment for a SPECT scan.  
 
 
 
 You have been asked to pay $295 for a SPECT scan. This item/service falls within the SPECT scan 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 reduce the copayment for a SPECT scan provided on July 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI with help guide the enrollee's treatment. The 
Plan denied your request. The Plan says the documentation does not show the MRI is necessary for the 
enrollee's condition. 
 
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 
MRI of the brain is not medically necessary. Our physician reviewer found that the enrollee is said to have a 
polyneuropathy. Performance of MRI of the brain is not a standard of practice/care in the evaluation of 
polyneuropathy. Rather, the evaluation of polyneuropathy does not readily involve the use of imaging of the 
head. Therefore, it cannot be said to be reasonable and necessary for the enrollee 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 a magnetic resonance imaging (MRI) of the brain without contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 31, 2020. Therefore, 
we decided that the Plan does not have to pay for the dental services on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on April 7, 2022. 
 
You asked the Plan to pay for CT scans. You say that the enrollee was discharged from hospice on April 6, 
2022, and did not go back into hospice until April 9, 2022. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on April 6, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a CT scan provided on 
April 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 16, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. However, you are only being asked 
to pay $61.96 which is less than the required amount. This item/service falls within the emergency care 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 emergency room visit provided on August 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for out-of-network Medicare Part B prescription 
drugs and an out-of-network office visit provided on March 28, 2022. 
 
You asked the Plan to waive the cost share for out-of-network Medicare Part B prescription drugs and an out-
of-network office visit. You say that you disagree with the cost share. The Plan denied your request. The Plan 
says this cost sharing was charged 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 20% 
coinsurance and a $55 copayment for out-of-network Medicare Part B prescription drugs and an out-of-
network physician/practitioner services/primary care physician.  
 
You have been asked to pay a 20% coinsurance for out-of-network Medicare Part B prescription drugs and a 
$55 copayment for an out-of-network office visit. The total allowed amount for the prescription drugs is 
$15.86. You are being asked to pay $7.93 ($15.86 x 50% = $7.93). The total amount you are being asked to pay 
for the services rendered $62.93 ($55 + $7.93 = $62.93). This item/service falls within the out-of-network 
Medicare Part B prescription drugs and an out-of-network physician/practitioner services/primary care 
physician 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 out-of-network Medicare 
Part B prescription drugs and an out-of-network office visit provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transport and 
clearly exceeds the criteria for an LTACH admission. The Plan denied your request. The Plan says based on 
Medicare guidelines, the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee had a fainting spell and the ambulance was called. You also say that the enrollee was evaluated and the 
neck and blood pressure were found to be okay. 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 September 22, 2022. 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 response and treatment with no 
transport provided on September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) service provided on October 
1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF service. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 skilled nursing facility (SNF) service provided 
on October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the outpatient hospital physician services. We 
decided that the Plan does not have to waive the copayment for the injections.  You asked the Plan to waive the copayment for the infliximab injections, the methylprednisolone sodium 
succinate injections and the outpatient hospital physician services provided on June 28, 2022, July 12, 2022, 
and August 9, 2022. You say that you cannot afford these higher costing copayments. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for the outpatient hospital physician services.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that physician services are covered in full in an ambulatory surgical center or 
outpatient hospital facility. The Plan says you must pay a $90 copayment for the physician services received in 
an outpatient hospital ($30 x 3 = $90). Based on the Plan contract, however, you cannot be asked to pay more 
than the contractual obligation for physician services received in an outpatient hospital setting. Therefore, we 
decided that the Plan has to waive the copayment for the outpatient hospital physician services. 
 
We also decided that the Plan does not have to waive the copayment for the injections. 
 
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% 
coinsurance for each Medicare-covered Part B drug. Therefore, we decided that the Plan does not have to 
waive the copayment for the injections. 
 
You have been asked to pay a cost-share of $668.94 for the injections ($3344.70 allowed amount x .20 = 
$668.94). These items/services fall within the Medicare Part B prescription drugs 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 infliximab injections and the methylprednisolone sodium 
succinate injections.   
 
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 pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for intervertebral disc degeneration of the lumbar 
region. The enrollee presented with chronic low back pain. In this case, there are multiple plausible pathologic 
sources of significant pain generation. The chronic back pain, the noted pain-aggravating factors (standing, 
walking, and bending), along with the painful spinal motion are all non-specific to any pathologic entities. 
Overall, the documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. The documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the enrollee does not meet criteria for the requested 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia. There is no indication that the examination is being 
requested in the context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found the documentation 
provided for review did not support that the enrollee readily meets diagnostic criteria for both Alzheimer's 
disease (AD) and frontotemporal dementia (FTD). Rather the notes suggested possible causes to be AD versus 
alcohol related encephalopathy and/or vascular dementia. There was no mention of FTD in the records. 
 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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iTIND device (53899, C9769). 
 
You asked the Plan to pre-approve an iTIND device. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is experimental/investigational. 
 
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 iTIND device. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that further studies are needed to evaluate the durability of temporary nitinol implantable device 
(TIND) outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate 
the advantages of second-generation device over the first-generation device. 
 
 
  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 iTIND device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an iTIND device (53899, C9769).