Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve CT scan. You say that this scan is medically necessary. The Plan denied 
your request. The Plan says that medical need for this request has not been shown. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
enrollee meets criteria for the requested CT scan. Our physician reviewer found the enrollee's serum lactase 
dehydrogenase (LDH) is elevated, and creatinine is elevated with glomerular filtration rate (GFR) at 58. The 
enrollee has middle back pain and urinary frequency. These findings and symptoms justify a CT scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has improved but you would like them 
to stay longer until the home is set up for them. The Plan denied your request. The Plan says that the enrollee 
does not meet Medicare criteria for a SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacing tooth #8 in your complete dentures (D5520) 
provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had two teeth replaced and the insurance 
only paid for one. 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 Plans 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 on date of service September 7, 2022. 
Therefore, we decided that the Plan does not have to pay for replacing tooth #8 in your complete dentures 
(D5520) provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99202, 0101T, and 97140 provided from 
August 19, 2022, to September 2, 2022. 
 
You asked the Plan to pay for codes 99202, 0101T, and 97140. You say that the treatment helped your pain and 
movement. The Plan denied your request. The Plan says the services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99202, 0101T, and 97140 provided from August 19, 
2022, to September 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a diagnostic colonoscopy and injections 
provided on August 30, 2022. 
 
You asked the Plan to waive the cost sharing for a diagnostic colonoscopy and injections. You say that you are 
on a fixed income and having to pay this is difficult. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $450 deductible which applies to outpatient surgery. Your contract 
with the Plan also says that you pay 10% for each Medicare-covered Part B drug obtained in a providers office 
or outpatient setting.  
 
The diagnostic colonoscopy you asked the Plan to waive the deductible for falls within the outpatient surgery 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 
deductible which applies to outpatient surgery.  
 
 You have been asked to pay $26.19 for injections. This item/service falls within the Medicare Part B 
prescription drugs benefit category. The amount you owe is $437.97 ($411.78 deductible + $26.19 coinsurance 
= $437.97). Therefore, we decided that the Plan does not have to waive the cost sharing for a diagnostic 
colonoscopy and injections provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for localized delivery of antimicrobial agents (D4381 x8), 
periodontal scaling and root planing (D4342 x3), adjunctive pre-diagnostic test (D0431), odontoplasty (D9971 
x2), and gingival irrigation  per quadrant (D4921 x4) provided on June 15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were advised by the dental office that 
there would be no charge for the services. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plan's cost sharing amount when your services are received from an out-of-
network provider. 
 
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.  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for localized delivery of antimicrobial agents 
(D4381 x8), periodontal scaling and root planing (D4342 x3), adjunctive pre-diagnostic test (D0431), 
odontoplasty (D9971 x2), and gingival irrigation  per quadrant (D4921 x4) provided on June 15, 2022.  
 
Your complaint about the providers office 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 4, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. However, you are only beng charged 
$238.54 which is less than the required amount. This item/service 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 services provided on June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and x-rays provided on June 9, 2022, to June 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit and radiology services. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 office visit and x-rays provided on June 9, 2022, 
to June 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with the copayment. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $350 copayment for CT scan. However, you are only being asked to pay $245.80 
which is less than the required amount. This item/service falls within the outpatient diagnostic tests/Medicare-
covered diagnostic radiology 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 
computed tomography (CT) scan
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claims are being denied for no valid reason. 
The Plan denied your request. The Plan says the code was not billed with a valid modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We find that CPT code A0429 was not billed with an origin and destination modifier suitable for payment. 
Furthermore, the Centers for Medicare and Medicaid services specifically instruct that the emergency triage, 
treat, and transport (ET3) model does not apply to Medicare advantage plans. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the ambulance services provided on March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair 
(E2377, E2313). 
 
You asked the Plan to pre-approve the expandable controller.. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary. 
 
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 expandable controller.. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the 
records show that the enrollee has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. 
 
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 expandable controller. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313).
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 medical records and clinical 
information provided states the enrollee meets the requirements for LTACH level of care. The Plan denied your 
request. The Plan says the member is receiving appropriate in-patient acute care and does not require transfer to 
a Long-Term Acute Care Hospital (LTACH). 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided on 
September 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the 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 (99307) provided 
on September 1, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tele dentistry provided on September 28, 2022. 
 
You asked the Plan to pay for tele dentistry. You say that you feel you should not have to pay for this visit. The 
Plan denied your request. The Plan says this service is not covered under your 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. Tele dentistry is not covered 
under the Plans dental benefits. 
 
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 tele 
dentistry provided on September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get the 
MRI done. The Plan denied your request. The Plan says the enrollee did not complete at least 6 weeks of 
provider directed treatment within the last 3 months; therefore, the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI of the left shoulder, in this case, is not medically reasonable or necessary. Our physician 
reviewer found that the enrollee was being treated for pain in the left shoulder and chronic pain. The enrollee 
presented with left shoulder pain, weakness, night pain, and difficulty sleeping. The exam reveals weakness 
with supraspinatus testing and subacromial crepitus. Neers, Hawkins, and painful abduction were all positive. 
There is a weakness with external rotation. 
 
However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. There is no indication the enrollee has tried and failed 
formal physical therapy. There are limited large-scale, long-term references showing the medical necessity of 
the requested imaging in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the upper extremity without contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on  
January 27, 2022 and May 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided on January 27, 2022 and May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a powered pressure-reducing air mattress is covered 
when the criteria listed in the Medicare Rules section is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a powered pressure-reducing air 
mattress. Our reviewer says that this item is not medically necessary. Our physician reviewer found the 
member does not have multiple stage 2 pressure ulcers located on the trunk or pelvis and has failed to improve 
in the previous month with conservative treatment with a comprehensive ulcer treatment program or a 
myocutaneous flap or skin graft.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).