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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found your medical conditions are stable and there are no complex nursing or rehabilitation
needs. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth #21.
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth #21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 a power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no indication zoledronic acid would likely be less effective, 
and/or cause adverse effects for the member. 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. The patient has not tried and failed zoledronic acid and 
does not have a history of osteoporotic fracture. There is no documentation provided indicating that zoledronic 
acid would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer 
found that the enrollee's condition does not meet step therapy criteria for Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia for the enrollee.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to waive the cost sharing for the physical therapy services. We decided that the
Plan does not have to waive the cost sharing for the skilled nursing facility (SNF) services.
You asked the Plan to waive the cost sharing for the SNF services and the physical therapy services. You say
that you were never advised of this cost sharing obligation. You stated that you were in regular contact with
the SNF social worker and the Plan and no one ever said anything about this copayment. The Plan says that
these copayments were charged correctly.
We decided that the Plan has to waive the cost sharing for the physical therapy services on August 3,
2020.
The Plan must follow Medicare rules. Medicare rules say that Plans are required to clearly disclose cost sharing
obligations to their enrollees. In this case, the enrollee was in the SNF from July 20, 2020, to August 18, 2020,
for a total of 28 days. In addition to being charged the copayment for the SNF services themselves (which will
be discussed below), the Plan charged a $10 copayment for outpatient physical therapy services the enrollee
received on August 3, 2020. We find that this copayment was charged incorrectly. The enrollee's Evidence of
Coverage explicitly states that SNF services include physical therapy services. The Plan has not stated in their
Evidence of Coverage that separate cost sharing would apply for these physical therapy services for SNF
residents. A reasonable reading of the contract would lead one to believe that the cost of any physical therapy
services would be encompassed within the SNF copayment itself. Therefore, we decided that the Plan has to
waive the cost sharing for the physical therapy services on August 3, 2020.
We also decided that the Plan does not have to waive the cost sharing for the SNF services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as
copayments, deductibles, and coinsurance). The contract with the Plan clearly says that members must pay a $0
copayment per day for days 1 to 20, and a $100 copayment per day for days 21 to 100 for SNF services. The
enrollee was in the SNF for 28 days. She was not charged a copayment for the first 20 days as per the contract.
For the remaining 8 days, she was charged a $100 copayment per day up to $438.91. At that point, the enrollee
had reached her out-of-pocket maximum for the year, which is why no additional cost sharing was applied. The
Plan has met its burden by clearly disclosing this cost sharing obligation in the Evidence of Coverage.
Therefore, we decided that the Plan does not have to waive the cost sharing for the SNF services.
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 reduce the cost for the eye exam provided by an out-of-network 
provider on June 21, 2021. 
 
You asked the Plan to reduce the cost for the eye exam. You say that you checked before making an 
appointment and he shows up as in-network. You say that you paid a $45 copayment at the office that day. The 
Plan denied your request. The Plan says the deductible applied correctly. 
 
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 your deductible is $500. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost for most of your covered services.

The item or service you asked the Plan to reduce the cost for falls within the "Vision care" benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to 
out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-
of-network eye exam was received on June 21, 2021. Therefore, we decided that the Plan does not have to 
reduce the cost for the eye exam provided by an out-of-network provider on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable


We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone graft at 
time of implant placement (D6104) provided on September 2, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration and bone graft. You say that this implant is a 
critical abutment to hold the partial denture in place. You also say that without this implant, you would have 
nothing to hold the partial in place and these services were necessary. The Plan denied your request. The Plan 
says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone 
graft at time of implant placement (D6104) provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on June 1, 
2021. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you have never been billed 
for your blood work by the clinic. The Plan denied your request. The Plan says you have been asked to pay 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 $30 
copayment per day, per provider for in-network Medicare-covered laboratory services. For this date of service, 
you have been asked to pay the allowed amount of the claim because this amount is less than the standard $30 
copayment for the laboratory work. 

You have been asked to pay a $9.71 copayment for the laboratory work. The laboratory work 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 the laboratory work provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full upper and lower denture.
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered once in a five year period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case, which says that dentures are covered once every five years. 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, as dentures were approved and paid for on December 5, 2017, less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a full upper and lower denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), periodontal maintenance (D4910), and 2D oral or facial photographic image (D0350) provided on June 21, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that the service was not completely covered by your plan. You also say that you are on a fixed income. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says 1 complete series x-ray is covered every 5 years. The Plan says that the frequency limits have been exceeded. The Plan says that periodontal maintenance has a 70% coinsurance when performed in network. The Plan also says 2D oral or facial photographic image is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation, complete series x-ray are listed as covered the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on January 7, 2021. The record shows that the Plan paid 30% for the periodontal maintenance. $84 x 30% = $25.20. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, 2D oral or facial photographic image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), periodontal maintenance (D4910), and 2D oral or facial photographic image (D0350) provided on June 21, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2331, D2332, D2391, D2392). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit, as the maximum benefit for fillings has already been covered for the 
calendar year. Therefore, we decided that the Plan does not have to pre-approve dental services (D2331, 
D2332, D2391, D2392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May
10, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal this
service because $94.11 was not paid on your dental bill. The Plan denied your request. The Plan says benefits
for this service have been satisfied and the frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation
(D0150) is limited to one procedure code every three years. The record shows that you received a
comprehensive oral evaluation (D0150) on January 25, 2019, and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on June 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the prophylaxis. You say that the doctor wants his patients to have their cleanings rendered by the hygienist. The Plan denied your request. The Plan says routine dental services provided by a non-Plan provider are not covered because they were not authorized by the Plan and not emergent needed.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on June 21, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you have no complex nursing or rehabilitation needs.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says you do not use insulin and only use Metformin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised gel cushion seat.
You asked the Plan to pre-approve a raised toilet seat. You say that this is needed due to pain and height. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised gel cushion seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift provided on May 3, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for seat lift. You say that you were never told of the correct procedure and you 
needed this chair. The Plan denied your request. The Plan says the denial of payment for this item is correct, 
because prior authorization is required but was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that 
no additional payment is made by Medicare for sales taxes. The contract with the Plan says that the Plan offers 
a Point-of-Service (POS) benefit that covers some out-of-network items and services. The contract with the 
Plan says that prior authorization is required for durable medical equipment (DME) items that cost more than 
$1,000. 
 
The requested provider in this case is not a network provider with the Plan. Although the Plan does offer POS 
coverage for DME, this item cost more than $1,000 and therefore is not covered by the Plan without prior 
authorization. We found no exception that would require the Plan to pay for these items/services. Furthermore, 
the sales taxes you requested reimbursement for are not paid by Medicare. Therefore, we decided that the Plan 
does not have to pay for a seat lift provided on May 3, 2021 by an out-of-network (OON) provider.