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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being 
provided in the current acute care setting which is already approved. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete denture-maxillary (D5110) and 
mandibular partial denture-cast metal framework with resin denture bases (D5214) provided on March 16, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you should not have a bill for these 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted during this visit, March 16, 2022. 
Therefore, we decided that the Plan does not have to pay more for the complete denture-maxillary (D5110) and 
mandibular partial denture-cast metal framework with resin denture bases (D5214) provided on March 16, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you already paid your $25 office 
copayment and should not need to pay more. The Plan denied your request. The Plan says the copayment 
applied was 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 a $40 
copayment for Medicare-covered X-rays.  
 
You have been asked to pay a $40 copayment for an x-ray. An x-ray 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 an x-ray provided on March 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2022, to 
January 23, 2022. 
 
You asked the Plan to pay for the home health services. You say the claim should be reprocessed for payment. 
The Plan denied your request. The Plan says that the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from January 12, 2022, to January 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DME (CPT code(s): E2377, E2311, E2313 and 
E2373). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (electronic 
connector to 3 power features) is not medically necessary. They are necessary when there is a medical need to 
control 2 or more power features though the joystick. The notes do not show a medical need to control the 
power features through the joystick. The power features can be controlled using their own switches. These 
switches can be made any size without asking for a separate request. They can be made from any material 
without asking for a separate request. All of this can be done without the need to use the joystick to control the 
power features. The specialty joystick is not covered when the enhanced/upgraded electronics are not covered. 
Therefore, we decided that the Plan does not have to pre-approve the DME (CPT code(s): E2377, E2311, 
E2313 and E2373).
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 requested admission is medically 
necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 the provided documentation shows that the enrollee does not require services at the 
LTACH that are not already available at the current facility. The reviewer found there are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, 
the reviewer found that the requested LTACH admission is not 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 28, 
2022, by an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the facility requested our services 
and typically these claims are processed and paid. The services were rendered in good faith and medically 
necessary. We depend on the office staff to verify eligibility and to obtain the proper authorization from the 
enrollee's Plan. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 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 subsequent nursing facility care provided on 
January 28, 2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 7, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were never transported 
so you shouldn't be charged. The Plan denied your request. The Plan says the copayment applied 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 $100 
copayment per one-way trip.  
 
You have been asked to pay $100 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on February 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that you would like the claim 
reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 ophthalmological services provided on 
February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 52001 billed for date of service September 
24, 2021. 
 
You asked the Plan to pay for procedure code 52001. You say that this service is supported in the record and 
was billed appropriately. The Plan denied your request. The Plan says payment for code 52001 is bundled into 
payment for code 52235. 
 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 52001 
is a column II code to column I code 52235. 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 52001 billed for date of service September 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
upper right and upper left quadrants, a crown (D2740) for tooth #8, and a core buildup, including any pins 
when required (D2950) for tooth #8. 
 
You asked the Plan to pre-approve the scalings and planings, crown, and core buildup. You say that you need 
the crown to be replaced before next year. The Plan denied your request. The Plan says these services exceed 
the maximum counts allowed per period. 
 
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, crown (D2740) and core buildup, 
including any pins when required (D2950) are each limited to one procedure per tooth every five plan years. 
The record shows that you received a crown (D2740) and core buildup (D2950) on tooth #8 on January 23, 
2018, and your crown (D2740) and core buildup (D2950) benefits for tooth #8 have been exhausted. The 
contract also says that periodontal scaling and root planing (D4341) is limited to one procedure per quadrant 
every two plan years. The record shows that you received scalings and planings (D4341) on the upper right and 
upper left quadrants on June 14, 2021, and your periodontal scalings and root planings (D4341) benefit for the 
upper right and upper left quadrants has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve periodontal scalings and root planings (D4341) of the upper right and upper left quadrants, a 
crown (D2740) for tooth #8, and a core buildup, including any pins when required (D2950) for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold cap. 
 
You asked the Plan to pre-approve a cold cap. You say that this is necessary for your condition. The Plan 
denied your request. The Plan says this is not a covered benefit by Medicare or the Plan. 
 
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 cold cap.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three interim crowns (D2799 x3). 
 
You asked the Plan to pre-approve the interim crowns. You say that financially you cannot afford to pay for 
these services. The Plan denied your request. The Plan says this service is 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 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 three 
interim crowns (D2799 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied tie-down kit. 
 
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 the services are not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve an unoccupied tie-down kit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from 
December 14, 2021, to January 12, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were told you could 
pay $30 copayment instead of the $35. The Plan denied your request. The Plan says the copayments applied are 
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 $35 
copayment for each therapy visit.  
 
You have been asked to pay $350 ($35 x 10 visits) copayment for physical therapy visits. Physical therapy 
visits fall within the Outpatient Rehabilitation 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 physical therapy visits provided from December 14, 2021, to January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you were told this would help with tooth 
grinding, lockjaw and headaches. The Plan denied your request. The Plan says this item is not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have pain related to osteoarthritis of the right shoulder. You have failed treatment with Tylenol, 
Advil and non-steroidal anti-inflammatories and Synvisc. The documentation does not support that you have 
tried and failed Durolane and Gelsyn-3. The documentation does not support that Durolane and Gelsyn-3 
would likely be less effective and/or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
3, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldn't have this 
charge. The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for specialist office visit.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5257) provided on September 17, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that you should have gone to a 
Plan approved hearing provider. The Plan denied your request. The Plan says you received these hearing aids 
from an OON provider. The Plan also says that there is no coverage if hearing aids, or related services are 
received from outside of the Plan's Hearing network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor for your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5257) provided on September 17, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve backrest push handles for an ultralight wheelchair. 
 
You asked the Plan to pre-approve push handles. You say that you cannot walk and might fall. The Plan denied 
your request. The Plan says the denial of authorization for this component is correct, because the requested 
push handles are not primarily medical in nature and are for the convenience of a caretaker. 
 
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 
primarily for the convenience of a caretaker. Therefore, we decided that the Plan does not have to pre-approve 
backrest push handles for an ultralight wheelchair.