Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on October 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 enrollee requires at least 3 hours a day /5 
days a week, or 15 hours over 7 consecutive days, of therapy services.  At this time, there is not a reasonable expectation that the enrollee would be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in the 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services (D7210, D7311, D0330, D5130, D7140 and D7210) 
provided on June 22, 2021, through August 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like reconsideration because these 
services are covered under your dental benefit. The Plan denied your request. The Plan says that these services 
have not been billed correctly 
 
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 has not forwarded sufficient information to support their 
denial rationale. There is no indication in the file as to why the services at issue have not been billed correctly. 
The Plan has not cited a valid rule on which they have based their denial. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for the dental services (D7210, D7311, D0330, 
D5130, D7140 and D7210) provided on June 22, 2021, through August 24, 2021.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided from September 7, 2021, to September 30, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility care. You say that the services should be covered as you thought it would fall under a new benefit period. The Plan denied your request. The Plan says the cost-sharing applied correctly, even though you went in for two separate injuries, they were both within 60 days and fall within the same benefit period.
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 $184 copayment per day for days 21-100 for Skilled nursing facility (SNF) care.
You have been asked to pay a $3,312 copayment per day for days 21-38 of skilled nursing facility care ($184 x 18 = $3,312). 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 skilled nursing facility care provided from September 7, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), provided on October 12, 2021. 
 
You asked the Plan to pay for the extraction. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not 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 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 the 
extraction (D7210), provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) provided September 13, 2021, to October 
7, 2021. 
 
You asked the Plan to pay for the abutment and abutment supported crown. You say that you were told that 
these services would be covered under your medical benefits. The Plan denied your request. The Plan says 
these services are not covered under your medical or dental benefits. 
 
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. These implant services are dental in nature and are not covered under 
your medical benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated 
abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided 
September 13, 2021, to October 7, 2021.  
 
Your complaint about potentially receiving misinformation from plan representatives 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for computed tomography (CT) scans provided 
on November 12, 2021. 
 
You asked the Plan to waive the deductible for the computed tomography (CT) scans. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible and a $125 copayment which applies to advanced 
imaging services.  
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category advanced 
imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to advanced imaging services. This cost sharing is a contractual obligation that 
had not been met at the time the computed tomography (CT) scans was received on November 12, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for computed tomography (CT) 
scans provided on November 12, 2021.  
 
Since the $750 deductible was met, you have also been asked to pay a $125 copayment. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be approved. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete dentures (D5110, D5120) provided on October 14, 2021. 
 
You asked the Plan to pay for the complete dentures. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exceeded the frequency limits set in the subscriber agreement 
 
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. Specifically, the documents submitted indicate you received these 
services in 2018. This means you have exceeded the maximum frequency allowed for this benefit. Therefore, 
we decided that the Plan does not have to pay for the complete dentures (D5110, D5120) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (86891, P9022, 99191, 99190, and 
99190-76) provided on June 30, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the medical services (86891, P9022, 99191, 99190, and 99190-
76) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for breast tomosynthesis provided on August 4, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
not covered separately. 
 
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 G0279 is diagnostic digital breast tomosynthesis, 
unilateral or bilateral (list separately in addition to 77065 or 77066). Incidental services that are necessary to 
accomplish the primary procedure are not separately billed. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
breast tomosynthesis provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the limited oral evaluation (D0140), provided on 
October 25, 2021. 
 
You asked the Plan to pre-approve the limited oral evaluation. You say that the service should be covered. The 
Plan denied your request. The Plan says you have exceeded the frequency limits set in the subscriber agreement. 
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. Specifically, the records submitted indicate you received this service 
on August 16, 2021. This means you have exceeded the maximum frequency allowed for this service. 
Therefore, we decided that the Plan does not have to pre-approve the limited oral evaluation (D0140), provided 
on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Cyclophosphamide, with supporting 
drugs Fosaprepitant, Ondansetron, and Dexamethasone. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the 
regimen is not being prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the requested drugs. Our physician 
reviewer found that the enrollee has ovarian cancer. The records show that her microsatellite instability (MSI) 
is stable, and her tumor mutation burden (TMB) is low. The requested use of the drug regimen is not FDA-
approved for the enrollee's diagnosis as she is not MSI high or TMB high. The requested use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
The use is not listed as not indicated, not supported or not recommended in any of the compendia. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 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 requested drugs have been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda and Cyclophosphamide, with supporting drugs Fosaprepitant, Ondansetron, and 
Dexamethasone.
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 does not meet 
criteria. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement. There is no indication that you would require skilled rehabilitation in 
an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain your functional status. You can receive further services at a lower level of 
care when ready for discharge from the hospital. 
 
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 pay for the comprehensive oral evaluation - new or established 
patient (D0150) and panoramic radiographic image (D0330) provided September 9, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and panoramic x-rays. You say that you were not 
aware of the frequency limit and would like the services to be covered by your dental allowance. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for these services. 
 
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 
comprehensive oral exam and panoramic x-rays once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and panoramic x-ray were previously covered on November 8, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral  exam and panoramic x-rays have been exceeded. Therefore, we decided that the Plan does not have to pay for  the comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided September 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the blood transfusion services provided from January 15, 2021, to 
January 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the code was billed without an appropriate modifier. 
 
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. 
 
In this case, the CPT Code Manual definition of code 36430 is Transfusion, blood or blood components. We 
looked at the file and the rules. The Plan has not identified the column 1 code for which their denial is based. If 
a code pair is not identified, there is no way to indicate whether a modifier needs to be appended. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the blood transfusion services provided 
from January 15, 2021, to January 17, 2021.  
 
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: 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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee can receive further services at a lower level of care. 
 
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.