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

 
We decided that the Plan has to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for 
this item. 
 
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. Specifically, the Plan contract states that complete dentures are a covered 
benefit; however, the contract does not state the allowable frequency for this dental item. Additionally, the Plan 
has stated that you have exhausted the allowable benefit for this item as you previously received a complete 
upper denture on February 9, 2022 that was paid for by the Plan. However, the Plan has not provided evidence 
that demonstrates this item was provided to you on this indicated day or that the Plan issued payment for this 
item. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided 
that the Plan has to pre-approve a complete upper denture (D5110).  
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the injection provided on November 2, 2022. We 
also decided that the Plan does not have to reduce the copayment for the specialist office visit.  
 
You asked the Plan to reduce the cost share for the specialist office visit and triamcinolone injection. You say 
that there was an error with this claim, and you needed reimbursement. The Plan says that this cost sharing was 
charged correctly. 
 
 
 We decided that the Plan has to waive the coinsurance for the injection.  
 
According to Medicare, the triamcinolone injection (J3301) that assessed a cost share amount is considered a 
packaged code and is not separately payable. This code is also excluded from the physicians free schedule. 
Therefore, we decided that the Plan has to waive the coinsurance for the injection provided on November 2, 
2022.  
 
We also decided that the Plan does not have to reduce the copayment for the specialist office visit. 
 
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 $50 
copayment for an in-network specialist office visit.  
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 
the specialist office visit provided on November 2, 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nubeqa. 
 
You asked the Plan to pre-approve Nubeqa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered anti-cancer drug requested here is not among the types which are 
covered by Medicare Part B because it does not have the same active ingredients as a non-self-administrable 
anti-cancer drug or biological. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Nubeqa.  
 
Benefits for Nubeqa may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the saline solution infusions provided on December 
7, 2022. We also decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on December 7, 2022.  
 You asked the Plan to waive the cost share for the specialist office visit and saline solution infusions. You say 
that you would like to appeal these charges. The Plan denied your request. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the saline solution infusions.  
 
You have been asked to pay 20% coinsurance for the saline solution infusions. According to Medicare, the 
saline injections (J7030 and J040) that assessed a cost share amount are considered packaged codes and are not 
separately payable. These codes are also excluded from the physicians free schedule. Therefore, we decided 
that the Plan has to waive the coinsurance for the saline solution infusions provided on December 7, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the specialist office visit. 
 
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 $10 
copayment for a specialist office visit.  
 
You have been asked to pay a $10 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 
the specialist office visit provided on December 7, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories 
(E0955, E0995, E1002, E1028, E2361, E2607, E2620, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee had a stroke 
and due to her immobility, she experiences hemiparesis of her right side, making her a substantial risk for falls. 
She is a heightened risk for developing pressure injuries due to prolonged sitting and her inability to 
redistribute weight. The requested wheelchair is medically necessary for the enrollee and her condition. The 
Plan denied your request. The Plan says the enrollee does not have medical need for single power options 
included with group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
right sided weakness after a stroke. She currently uses a scooter. She has good strength in left arm per her 
medical doctor. The enrollee does not have a high risk for skin breakdown, and she has a chronic condition of 
impaired mobility and no skin issues. She does not use a catheter intermittently and has no significant 
spasticity. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories (E0955, 
E0995, E1002, E1028, E2361, E2607, E2620, K0040).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says that the requested continued 
admission to a SNF does not meet criteria. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have a recent past medical history of hospitalization related to humeral fracture, 
L3 radiculopathy. Clinical documentation shows that you have multiple medical issues s/p acute 
medical/functional status change (and beneath Past LOF) thus requires skilled therapy and nursing assessment. 
Documentation from team recommends ongoing daily skilled therapy services and shows you are still requiring 
physical assist/DME evaluation thus, daily skilled services on an inpatient basis in a SNF is medically 
necessary. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve budesonide capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that this medication would benefit the 
enrollee greatly. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve budesonide capsules.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), removal of impacted tooth - completely bony (D7240), coronectomy  
intentional partial tooth removal (D7251), and therapeutic parenteral drugs, two or more administrations, 
different medications (D9612). 
 
You asked the Plan to pre-approve codes D4265, D7240, D7251, and D9612. You say that n?A The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), removal of impacted tooth - 
completely bony (D7240), coronectomy  intentional partial tooth removal (D7251), and therapeutic parenteral 
drugs, two or more administrations, different medications (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on September 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the sleep study. You say that the services were medically necessary. The Plan 
denied your request. The Plan says 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 at issue in this case is not a network provider with the Plan. 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 sleep study. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee underwent diagnostic follow up 
testing. It would have been medically reasonable to delay services until they returned to the service area. 
 
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 sleep study have not been met.  
 
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 pay for the sleep study. Therefore, we decided that the Plan does 
not have to pay for a sleep study provided on September 27, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 27, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with 
the copayment applied to this service. 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 in-network emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
in-network emergency room 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 
an emergency room visit provided on November 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cholecystectomy provided on August 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the cholecystectomy. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says 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 at issue in this case is not a network provider with the Plan. 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 cholecystectomy. Our reviewer says that the records do not indicate that the 
care provided was medically necessary. Our physician reviewer found the records do not support that the 
services were emergently performed. It would have been medically reasonable to delay services until the 
enrollee returned to the service area. 
 
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 cholecystectomy have not been met.  
 
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 pay for the cholecystectomy. Therefore, we decided that the Plan 
does not have to pay for a cholecystectomy provided on August 30, 2022, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74019 billed for date of service July 16, 
2022. 
 You asked the Plan to pay for procedure code 74019. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 74019 is bundled into payment for code 
74021. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74019 
is a column II code to column I code 74021. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74019 billed for date of service July 16, 2022.
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 the enrollee needs physical therapy and cannot stay 
safely alone in their home. You say the enrollee cannot sit up, stand, or walk without assistance. The Plan 
denied your request. The Plan says based on Medicare rules and the enrollee's personal care needs, admission 
to a SNF is denied. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service June 7, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the codes were billed as ordered. The Plan 
denied your request. The Plan says the billed codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The lab results do not show that 
22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code G0483 billed for date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) equipment provided on November 19, 2022. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment. 
You say that you have never had to pay for this equipment 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous positive airway pressure (CPAP) equipment. 
This item/service falls within the durable medical equipment and related 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. The total you are being asked to pay is 
$16.60, which is 20% coinsurance of the allowed amount for the CPAP equipment ($83 allowed amount x 20% coinsurance = $16.60). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
continuous positive airway pressure (CPAP) equipment provided on November 19, 2022.