Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) home health visits 
(G0151). 
 
You asked the Plan to pre-approve 5 additional PT home health visits. You say that the requested home health 
PT visits are medically necessary. The Plan denied your request. The Plan says the additional PT home health 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 5 additional PT home health visits. Our 
reviewer says that the requested home health physical therapy visits are not medically necessary. Our physician 
reviewer found the provided documentation indicates that the enrollee appears to have plateaued with therapy. 
The reviewer found that further skilled therapy at this point does not appear to be likely to achieve any 
significant improvement in the enrollee's symptoms or functional status. Instruction has been provided to her 
caregivers for safety, mobility and transfers. Therefore, the reviewer found that the requested home health 
services are not medically reasonable or 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 5 additional PT home health visits have not been met. Specifically, the file 
shows that the enrollee has plateaued with therapy. Therefore, we decided that the Plan does not have to pre-
approve 5 additional physical therapy (PT) home health visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on May 6, 2021. 
 
You asked the Plan to pay for the denture. You say that you want a refund of the total amount you paid for this 
service, and you were unhappy with the care you received. The Plan denied your request. The Plan says this 
service is not covered by your dental benefit. In addition, the Plan states that you received the amount 
requested for reimbursement from the provider. 
 
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 
complete upper denture (D5110) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6059) for tooth # 10. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee has an existing crown over their 
implant that is failing. You say that the enrollee is very unhappy with this. You also say that the enrollee would 
like this service to be covered. The Plan denied your request. The Plan says abutment supported crown 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, the requested abutment supported 
crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve an abutment supported crown (D6059) for tooth # 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on September 10, 2021. 
 
You asked the Plan to pay for the dental items. You say that you were advised that you were covered for a $700 
dental allowance per calendar year. The Plan denied your request. The Plan says the provider in this case has 
opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.  
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, payment cannot be made to providers 
that have opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the complete 
upper denture (D5110) and complete lower denture (D5120) provided on September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Xiidra eye drops.  
 
Benefits for these services 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 a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental item. You say that you are having issues eating. You also say that 
you have damage to the lower part of your mouth. The Plan denied your request. The Plan says 1 lower partial 
denture is covered per plan year. The Plan also says that the frequency limit has been reached. 
 
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 lower partial denture is listed as 
covered, the frequency limit of one every 5 plan years has been reached. The record shows that the Plan paid 
for a lower partial denture that you received on May 1, 2019. Therefore, we decided that the Plan does not have 
to pre-approve a partial lower denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placements (D6010 x 14). 
 
You asked the Plan to pre-approve the dental services. You say that you have difficulty eating. You also say 
that you have discomfort using removable teeth. The Plan denied your request. The Plan says dental implants 
and all associated services are excluded from coverage. 
 
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 implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
placements (D6010 x 14).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 26, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment for this service. The Plan denied your request. The Plan says this code is not separately 
payable.  The Plan says it has reprocessed the other denied codes from this date of service.  
 
The Plan must follow Medicare rules. Medicare rules say that payment for codes with a status indicator of B on 
the Medicare Physician Fee Schedule is always bundled into payment for other services.  No separate payment 
is made for these codes. Procedure code 99100 has a status indicator of B on the Medicare Physician Fee 
Schedule. Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of 
service April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation services 
provided on October 21, 2021, and November 17, 2021. We also decided that the Plan does not have to waive 
the copayment for ambulance transportation services provided on November 19, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the bills are getting 
expensive and the enrollee cannot afford them. The Plan denied your request. The Plan says the enrollee has 
been charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for each one-way ambulance trip.  
 
The enrollee has been asked to pay a $300 copayment for each of the three ambulance trips, for a total of $900. The ambulance transportation falls within the Ambulance Services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for ambulance transportation services provided on October 21, 2021, 
and November 17, 2021. We also decided that the Plan does not have to waive the copayment for ambulance 
transportation services provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical injection service provided on 
August 13, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you should be refunded this 
copayment because the treatment for your pain was short-lived. The Plan denied your request. The Plan says 
the copayment amount you are being charged is correct. 
 
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 $40 
copayment for outpatient surgery physician service at an outpatient hospital facility.  
 
You have been asked to pay $40 copayment for outpatient surgery physician service. Outpatient surgery 
physician service falls within the Outpatient Surgery, Including 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 surgical injection service 
provided on August 13, 2021.  
 
Your complaint about the effectiveness of this treatment is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nucleic acid culture testing provided on September 30, 
2021, billed with 11 units of code 87150. 
 
You asked the Plan to pay for the culture testing as billed. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says the POS code reported is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the culture testing as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the nucleic acid culture testing provided on September 30, 2021, billed with 11 
units of code 87150.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the lab services provided on May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dupixent (C9399) and the administration (96372) 
provided on September 27, 2021. 
 
You asked the Plan to pay for the Dupixent and administration. The Plan denied your request. The Plan says 
Dupixent is listed as not eligible for Medicare coverage. 
 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. The governing Local Coverage Article (LCA) lists this drug as self-administered. Therefore, 
we decided that the Plan does not have to pay for the Dupixent (C9399) and the administration (96372) 
provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on November 8, 2021. 
 
You asked the Plan to pay for gingival irrigation. You say that you did not know that you were not receiving a 
standard cleaning and feel you should not be responsible for services when you were not told they would not be 
covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit. The 
Plan also states that your treatment plan, which was signed by you, does show that there will be $0 insurance 
coverage for the gingival irrigation service. 
 
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 gingival 
irrigation (D4921) provided on November 8, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the documentation does not support that the complexity of your nursing, medical 
and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that you require at least 3 hours of therapy per day at 
least 5 days per week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that you are 
reasonably expected to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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. 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 dental services with an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that you want to see this provider. The 
Plan denied your request. The Plan says out-of-network dental care is not covered by your benefit. There are 
in-network providers available to provide the necessary services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plans rules say that 
dental care is only covered when received from an in-network provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-
network providers are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve dental services with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on July 21, 2021. 
 
You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says on June 10, 2021 
the Plan paid for eyeglasses provided to the member on June 1, 2021. Therefore, the denial of payment for 
contact lenses purchased on July 21, 2021 is correct. 
 
Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that 
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these 
services every 2 years.  
We looked at the file and the Plan's rules. The file shows that the Plan paid for eyeglasses provided on  
June 1, 2021, and you have exceeded the maximum benefit limit for eyewear. Based on this information, we 
decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that 
the Plan does not have to pay for contact lenses provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zoledronic acid (J3489) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network care. You say that the requested treatment is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
services have not been met. 
 
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 
treatment with Zoledronic acid (J3489) to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services you provided to the enrollee on August 19, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you forgot to submit an authorization request 
to the Plan for this visit, but you would like retro authorization. The Plan denied your request. The Plan says 
unauthorized, non-plan 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. 
 
You are 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 medical services you provided to the enrollee on August 19, 2021.