Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for batteries for your motorized wheelchair received on July 5, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for batteries for your motorized wheelchair. You say that the provider did not come 
to fix your problem so you had to purchase batteries for your motorized wheelchair. The Plan denied your 
request. The Plan says the items received are not a covered benefit when provided by an OON provider. 
 
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 batteries for your motorized wheelchair received 
on July 5, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received on 
June 22, 2021, to June 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that your catheter was 
put in wrong, causing complications.  This hospital stay was part of those complications and you don't think 
you should have to pay for it. The Plan denied your request. The Plan says you were charged this copayment 
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 $295 
copayment per day for days 1-6 for inpatient hospital services.  
 
You have been asked to pay a $295 copayment per day for the inpatient hospital services. This copayment 
applies regardless of the reason for the services. 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 
inpatient hospital services you received on June 22, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) provided on April 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99204) provided on April 19, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 28 and 29 and retainer 
crowns (D6740) for tooth #'s 27 and 30. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you have two missing teeth, 
and it is very hard for you to chew your food. The Plan denied your request. The Plan says the documentation 
received fails to indicate any specific needs or conditions that preclude the use of a removable prosthesis. 
 
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. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns. Our 
reviewer says that the documentation provided does not meet the criteria for coverage for a fixed bridge. Our 
physician reviewer found there was no indication that a removable partial denture was contraindicated. Our 
reviewer found that there are multiple missing mandibular posterior teeth bilaterally. The criteria  for coverage 
for a posterior fixed bridge does not apply if multiple posterior teeth are missing. Our physician reviewer also 
found that posterior fixed bridges are not covered unless there is a medical reason that a removable partial 
denture is contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 28 and 29 and retainer crowns (D6740) for 
tooth #'s 27 and 30.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received on June 30, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you do not believe this test should have 
a copayment assigned to it. The Plan denied your request. The Plan says you were charged this copayment 
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 $15 
copayment for non-radiological diagnostic tests, x-rays, and ultrasounds.  
 
You have been asked to pay a $15 copayment for the TTE. The TTE falls within the non-radiological 
diagnostic tests, x-rays, and ultrasounds 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 transthoracic echocardiography (TTE) you received on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on June
22, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you had a catheter that
was put in wrong, causing you complications. You stated that this resulted in ambulance charges and you don't
think you should have to pay for them. The Plan denied your request. The Plan says you were charged this
copayment 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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the ambulance services. 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
services you received on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to 
pay more for the first intraoral periapical x-ray (D0220) provided on May 25, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation or pay more for the first intraoral 
periapical x-ray. You say that you believe you should be reimbursed for these services. The Plan denied your 
request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitation in your 
benefit plan. The Plan also says that your liability was applied correctly per your plan benefits for the first 
intraoral periapical x-ray. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 12, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. You are also responsible for the difference between the billed amount and 
the allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan 
does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for the first 
intraoral periapical x-ray (D0220) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein surgery (36475). 
 
You asked the Plan to pre-approve varicose vein surgery. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says there is no evidence conservative therapy has 
failed. 
 
The Plan must follow Medicare rules. Medicare rules say that varicose vein surgery is medically necessary 
when conservative therapy has failed.  
 
We looked at the file and Medicare rules. In this case, the medical records provided do not demonstrate that 
conservative failed has been adequately tried at this time. Based on this information, we decided that Medicare 
rules for coverage of varicose vein surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve varicose vein surgery (36475).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on February 23, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 wound care supplies provided on February 23, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 2, 2021.
You asked the Plan to pay for the scaling. You say that this claim was denied by the Plan saying the dentist you chose was out-of-network, but you contacted the Plan and were advised that this treating provider was in-network. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 2, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the enrollee's iron is extremely low, and she needs the
injection to build her iron level up. The Plan denied your request. The Plan says that the denial of authorization
for this drug is correct, because Retacrit is not being requested under medically accepted standards of
transferrin level of at least 20% and a ferritin level of at least 100ng/ml within the last 4 months.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Retacrit. Our reviewer says that the
enrollee meets the Medicare criteria for the requested use of Retacrit. Our physician reviewer found DrugDex,
a Medicare-approved drug compendium states that epoetin alfa compared with placebo significantly increased
the proportion of patients achieving an erythroid response through week 24, and also reduced red blood cell
(RBC) transfusions and increased the time to first transfusion in a randomized trial in patients with anemia and
low-risk myelodysplastic syndrome. Anemic low-risk myelodysplastic patients treated with erythropoietin with
or without granulocyte colony-stimulating factor and supportive care experienced improved erythroid
responses compared to those treated with supportive care only, while overall survival and incidence of
transformation to acute myeloid leukemia were similar in a randomized study. In this case, the record indicates
that the enrollee has myelodysplastic syndrome with low erythropoietin level. The requested Retacrit is being
used for a medically accepted indication as described by Medicare rules. The record establishes the medical
necessity and reasonableness, as defined by Medicare rules, of the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve
use of Retacrit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from
July 9, 2021, to July 26, 2021.
You asked the Plan to pay for the SNF admission. You say that you feel these services should be covered
because the enrollee has had a decline in health over the past year. You also say that services in a personal care
facility would not have been better. The Plan denied your request. The Plan says the enrollee did not meet
criteria for coverage of skilled level of care during these dates of service, as the enrollee does not have a skilled
physical therapy or nursing need.
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 pay for the SNF admission. Our reviewer says that
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) admission provided from July 9, 2021, to July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray services provided on April 23, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and x-ray services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and x-ray services provided on 
April 23, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection procedure (64479).
You asked the Plan to pre-approve an epidural injection procedure. You say that this request is medically
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been
met.
The Plan follows Medicare rules. Medicare rules say that an epidural injection is subject to the criteria listed 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 an epidural injection procedure. Our
reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer
found that there is no documentation of non-radicular thoracic back pain with failure of 4 weeks of nonsurgical
care, documented thoracic pain greater than or equal to 3/10 on visual analog scale, functional
impairments in activities of daily living, substantial imaging abnormalities, severe degenerative disc disease or
discogenic pain. The review indicates that the enrollee did not satisfy the coverage criteria for the requested
epidural injection procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an epidural injection procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve an epidural injection procedure (64479).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation coded with code 64999 provided on 
January 5, 2021. 
 
You asked the Plan to pay for radiofrequency ablation. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 radiofrequency ablation. Our reviewer says 
that the documentation does not support that the Our physician reviewer found the enrollee has a history of 
chronic neck and shoulder pain.  The enrollee has been treated with medical therapy and other conservative 
treatments. In January 2021 the enrollee had radiofrequency facet nerve root ablation at C4-5, C5-6, and C6-7 
bilaterally for 120 seconds at 42 degrees Celsius resulting in 40% improvement of the enrollee's pain. Non-
thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 
degrees Celsius), laser neurolysis, and cryoablation. Therefore, the enrollee did not meet criteria for the 
services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pay for radiofrequency ablation coded with code 64999 provided on January 5, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided June 1,
2021, to June 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were being treated
for the coronavirus and should not owe a copayment. The Plan denied your request. The Plan says the
coronavirus waiver of cost shares is no longer in effect.
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 $250
copayment each day for days 1-6 and $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a total cost share of $1500 for the inpatient hospital care. This care falls within the
inpatient hospital care benefit category. Although the Plan did waive coronavirus cost shares, this ended March
31, 2021. 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 inpatient hospital care provided June 1,
2021, to June 8, 2021.