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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that continuation of SNF services is medically 
necessary. The Plan denied your request. The Plan says continued admission in a SNF does not meet the 
requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral image (D0230), and fluoride varnish 
(D1206) provided on November 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you think these services should be paid. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
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 intraoral imaging was exhausted on date of service November 18, 2022. D1206 is not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for an additional intraoral image 
(D0230), and fluoride varnish (D1206) provided on November 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan provided on March 29, 2022. 
 
You asked the Plan to pay for CT scan. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for CT scan provided on 
March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy provided on 
November 21, 2022, and November 22, 2022. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you believe you were 
charged the incorrect coinsurance amount. 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 20% 
coinsurance for each radiation therapy service provided at an in-network outpatient hospital.  
 
You have been asked to pay $708.80, which is 20% coinsurance of the allowed amount for the radiation 
therapy provided on November 21, 2022 ($3,544 allowed amount x 20% coinsurance = $708.80). You have 
also been asked to pay $545.71, which is 20% coinsurance of the allowed amount for the radiation therapy 
provided on November 22, 2022 ($2,728.56 allowed amount x 20% coinsurance = $545.71). You have been 
asked to pay a total of $1,254.51 ($708.80 coinsurance + $545.71 coinsurance = $1,254.51). These items/services fall 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 coinsurance for the radiation therapy provided on November 21, 2022, and November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on August 25, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory drug testing 
provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 03, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
This patient needs your maintenence and care. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional retainer crown (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted with the plans authorization of 3 pontics and 1 retainer 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. 
 
 
  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 will be exhausted by April 27, 2023, with the plans 
authorization of these services from January 27, 2023, to April 27, 2023. Therefore, we decided that the Plan 
does not have to pre-approve the additional retainer crown (D6740). Therefore, we decided that the Plan does 
not have to pre-approve an additional retainer crown (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 
endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need these compression 
stockings. The Plan denied your request. The Plan says the requested compression stockings are not covered 
benefits. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the left breast biopsy performed by an in-
network provider on September 19, 2022, the specialist visit provided by an in-network provider on September 
22, 2022, and the placement of a breast localization device performed by an in-network provider on September 
28, 2022. 
 You asked the Plan to waive the copayment for the biopsy, the specialist visit, and the placement of the breast 
device. You say that you do not agree with the cost sharing applied to these services. 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 $250 
copayment for each in-network Medicare-covered outpatient surgery or procedure at an outpatient hospital 
facility or ambulatory surgical center, and a $30 copayment for in-network services obtained from a specialist, 
or under certain circumstances, by a nurse practitioner or physicians assistant or other non-physician health 
care professionals. 
 
You have been asked to pay a $250 copayment for the biopsy. You have also been asked to pay a $250 
copayment for the placement of the breast device. These items/services fall within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
You have also been asked to pay a $30 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category.  
 
You have been asked to pay a total cost share of $530 for the biopsy, the specialist visit, and the placement of 
the breast device. 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 left breast biopsy performed 
by an in-network provider on September 19, 2022, the specialist visit provided by an in-network provider on 
September 22, 2022, and the placement of a breast localization device performed by an in-network provider on 
September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and additional intraoral 
images (D0220/D0230), provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services to monitor an 
infection. 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 a periodic oral evaluation was exhausted on date of service on May 16, 2022, and 
November 18, 2022, and D0220 and D0230 was exhausted on November 18, 2022.Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120), and additional intraoral images 
(D0220/D0230), provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 27, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on December 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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 
physical therapy visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a steroid injection provided on October 28, 
2022.  
 
You asked the Plan to waive the copayment for an injection. You say that you have never had a facility charge 
before. 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 $275 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $275 copayment for an injection. This item/service falls within the outpatient 
surgery and other medical 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 a steroid injection provided on 
October 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a magnetic resonance imaging (MRI) and a 
gadoterate meglumine injection provided on October 24, 2022.  
 
You asked the Plan to waive the cost share for an MRI and an injection. You say that you are unsure why the 
Plan will not cover an ordered MRI. 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 $115 
copayment for Medicare covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility. Your contract with the Plan also clearly says that you must pay 
a 20% coinsurance Medicare-covered Part B drugs other than allergy antigens.  
 You have been asked to pay a $115 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $4.16 
coinsurance for an injection ($20.80 allowed amount x 20% coinsurance = $4.16 applied coinsurance). This 
item/service falls within Medicare Part B 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 
cost share for a magnetic resonance imaging (MRI) and a gadoterate meglumine injection provided on October 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2751). 
 
You asked the Plan to pre-approve crowns. You say that you would like the plan to approve this dental work. 
The Plan denied your request. The Plan says that the requested services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to send in a 2023 Evidence of Coverage (EOC). Therefore, 
we decided that the Plan has to pre-approve crowns (D2751).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. The 
provider sent insufficient medical records. Therefore, we decided that the Plan does not have to pre-approve 
SSBCI benefits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
12, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. 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 $40 
copayment for outpatient diagnostic tests/laboratory services. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/laboratory 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 laboratory services provided on October 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 30, 2022, to July 3, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were given 
conflicting information about the coverage for this stay. 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 $300 
copayment per day for days 1-6 of each in-network inpatient hospital stay.  
 
You have been asked to pay a $300 copayment per day for days 1-3 the inpatient hospital stay. You have been 
asked to pay a total of $900 ($300 copayment per day x 3 days = $900). You have not been charged for the day 
you were discharged. This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from June 30, 2022, to July 3, 
2022.