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

 
We decided that the Plan has to pay for the inpatient behavioral health services provided from December 10, 
2021, to December 14, 2021. 
 
You asked the Plan to pay for the inpatient behavioral health services. You say that the uncovered days should 
be authorized and approved. The Plan denied your request. The Plan says that the medical necessity criteria 
were not met for an acute inpatient stay after December 9, 2021. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health services 
provided from December 10, 2021, to December 14, 2021. Our reviewer says that the health plan's denial of 
continued inpatient psychiatric services is inappropriate. Our physician reviewer found it was expected this 
enrollee would improve in a reasonable period of time for the dates in question as although she did not have 
suicidal or homicidal ideation, auditory or visual hallucinations this patient continues to have depressive 
symptomatology and was undergoing active treatment. Our reviewer also found that it did appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care. 
 
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 inpatient behavioral health services provided from December 10, 2021, to 
December 14, 2021 have been met. Therefore, we decided that the Plan has to pay for the inpatient behavioral 
health services provided from December 10, 2021, to December 14, 2021.  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided October 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a professional 
component / technical component (PC/TC) indicator of 1. Services were billed with place of service 22, 
outpatient hospital. Payment for this service is included in the facility payment. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (88305) provided October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza virus vaccine provided on October 6, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the flu shot. You say that you have never had a claim denied for a flu shot 
before. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
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 the influenza virus vaccine provided on October 6, 
2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 14, 2021. 
 
You asked the Plan to pay for physician's services. You say that the patient was not in Hospice care on this date 
of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the members terminal condition. The Medicare hospice 
benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date 
of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician 
services and all care unrelated to the terminal illness until the first day of the month following the month in 
which hospice was revoked or discharged. 
 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 physician's services provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve P Pod Activity Chair and accessories. 
 
You asked the Plan to pre-approve P Pod Activity Chair and accessories. You say that the items are necessary. 
The Plan denied your request. The Plan says Medicare does not cover the activity chair since it is not a mobility 
device and is primarily nonmedical. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve P Pod Activity Chair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) and a power seat elevation feature (E2300) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a 
power seat elevation feature. You say that the requested items are a medical necessity for you. The Plan denied 
your request. The Plan says medical necessity rules for an expandable controller with harness and electronic 
connection have not been met and a power seat elevation feature is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that a power seat elevation feature is not primarily medical in 
nature. 
 
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 expandable controller with harness 
and electronic connection and a power seat elevation feature. Our reviewer says that an expandable controller 
with harness and electronic connection are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have a neurologic disorder with functional deficits. The requested electrical 
accessories are not medically necessary as you do have use of the upper extremity and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. An expandable controller with harness and 
electronic connection is not medically necessary. A power seat elevation feature is not a covered benefit. Based 
on this information, we decided that Medicare rules for coverage of an expandable controller with harness and 
electronic connection and a power seat elevation feature have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection 
(E2311) and a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 
You asked the Plan to pre-approve the Prolia injections. You say that you feel that the requested drug should be 
covered. The Plan denied your request. The Plan says a trial of oral and injected bisphosphonates is required 
before Prolia can be approved. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia injections. Our reviewer says 
that the requested drug is not considered medically necessary based on step therapy criteria. Our physician 
reviewer found the enrollee has a diagnosis of Age-related osteoporosis without current pathological fracture. 
The case file does not contain documentation that oral and IV bisphosphonates have been tried and failed. The 
documentation does not support that oral and IV bisphosphonates would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. 
 
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 Prolia injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nu-Step T-5 Recumbent Cross trainer (CPT code 
A9900). 
 
You asked the Plan to pre-approve the Nu-Step T-5 Recumbent Cross trainer. You say that you are requesting 
DME Nu-Step T-5 Recumbent Cross Trainer for treatment of your heart. You state that you have been advised 
that you are in need of this for your heart and you cannot go to the gym due to other health issues and COVID-
19. The Plan denied your request. The Plan says the requested Nu-Step T-5 Recumbent Cross trainer is not 
primarily and customarily used to serve a medical purpose. The Plan states this Nu-Step T-5 Recumbent Cross 
trainer is commonly used by persons without illness or injury and the requested recumbent cross trainer does 
not meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Nu-Step T-5 Recumbent Cross trainer (CPT code A9900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 4, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit (99214) provided on March 4, 2021 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance guided focused ultrasound 
(MRgFUS) for the enrollee 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough research to know if or how well this request works to treat people 
with Parkinson's Disease. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has Parkinson's disease and is being considered for surgical 
intervention for tremors. There is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's condition. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service.The elements of the coverage criteria are 
not satisfied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance guided focused ultrasound (MRgFUS) for the enrollee
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99282) provided 
on January 18, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 the emergency room visit. 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 (99282) provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services have 
been provided out-of-network and were not approved in advance. 
 
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 the office visit provided on February 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have reimbursement for the surgical extractions (dental code D7210) and 
sedation (dental code D9248) for tooth #22, #23, #24, #25, #26, and #27 provided by on December 29, 2021. 
 
You asked the Plan reimbursement for the surgical extractions and sedation. You say that you were told that the 
services would be covered, and you would like to be reimbursed for the procedure. The Plan denied your 
request. The Plan says these services are not covered by the Plan's dental benefits and it was confirmed the Plan 
never advised the enrollee that the services would be 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 reimbursement for 
the surgical extractions (dental code D7210) and sedation (dental code D9248) for tooth #22, #23, #24, #25, 
#26, and #27 provided by on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and core buildup, including any 
pins when required (D2950) provided on March 24, 2022, and March 30, 2022. 
 
You asked the Plan to pay for the consultation and core buildup. You say that you would like to appeal these 
services. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. The Plan also says that during your call to the Plan, you were advised multiple times that code 
D9310 is not covered, and there was no discussion about core buildups. 
 
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 
consultation (D9310) and core buildup, including any pins when required (D2950) provided on March 24, 
2022, and March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tire (CPT code E2211), insert for 
pneumatic propulsion tire (removable) (CPT code E2213) and transit option (CPT code K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic propulsion tire (CPT code E2211), insert for 
pneumatic propulsion tire (removable) (CPT code E2213) and transit option (CPT code K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration), 
one intraoral - periapical each additional radiographic image, Intraoral  periapical first radiographic image 
and a limited oral evaluation  problem focused on March 9, 2022. 
 
You asked the Plan to pay for endodontic therapy, molar tooth (excluding final restoration), one intraoral - 
periapical each additional radiographic image, Intraoral  periapical first radiographic image and a limited 
oral evaluation  problem focused. The Plan denied your request. The Plan says endodontic therapy, molar 
tooth (excluding final restoration), one intraoral - periapical each additional radiographic image, Intraoral  
periapical first radiographic image and a limited oral evaluation  problem focused are not covered 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 pay for 
endodontic therapy, molar tooth (excluding final restoration), one intraoral - periapical each additional 
radiographic image, Intraoral  periapical first radiographic image and a limited oral evaluation  problem 
focusedon March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has to pay for complete lower dentures (D5120) and complete upper dentures 
(D5110) provided by a network provider on April 8, 2022. 
 
You asked the Plan to pay for the complete lower and upper dentures (D5120, D5110). You say that you never 
received the dentures from the first dentist you saw last year. You say you did receive the dentures from this 
year's appointment. The Plan denied your request. The Plan says that the maximum dollar amount for this 
benefit has been reached. The Plan says you will not be responsible for any portion of the bill. 
 
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 did not submit documentation showing that they previously paid for 
dentures, nor did they submit any information showing the maximum dollar amount paid in 2022. This means 
we cannot determine if the denial of the services is supported. Therefore, we decided that the Plan has to pay 
for complete lower dentures (D5120) and complete upper dentures (D5110) provided by a network provider on 
April 8, 2022.  
 
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.