Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603) and comprehensive oral evaluation (D0150) provided on October 4, 2021.
You asked the Plan to pay for the caries risk assessment and documentation and comprehensive oral evaluation. You say that you did not switch dentists because you felt like it, it was a necessary move on your part. The Plan denied your request. The Plan says the caries risk assessment and documentation is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral evaluation exceeds the frequency limitation in 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, caries risk assessment and documentation (D0603) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on August 1, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603) and comprehensive oral evaluation (D0150) provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV).
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 medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records show that you have a mobility deficit but that it does not significantly impair your ability to complete mobility-related activities of daily living (MRADLs) in the home. You are impaired for bathing and dressing but have an aid for these activities. You are not able to use a manual wheelchair due to chronic right wrist tendinitis but the physical exam is not clear that you have tendinitis.
The exam does not indicate evidence of unsteadiness and states you are using a cane with slow gait. The POV is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an endosteal implant body (D6010), a surgical access to an implant body (D6011) and a bone graft at time of implant placement (D6104) on tooth #10.
You asked the Plan to pre-approve a surgical placement of an endosteal implant body, a surgical access to an implant body and a bone graft at time of implant placement. You say that you do not agree with the denied services. The Plan denied your request. The Plan says the requested services are 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 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 pre-approve a surgical placement of an endosteal implant body (D6010), a surgical access to an implant body (D6011) and a bone graft at time of implant placement (D6104) on tooth #10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) of
the shoulder provided on October 25, 2021.
You asked the Plan to reduce the copayment for a shoulder MRI. You say that when you had the MRI done you
were told you only had a $50 copayment. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180
copayment for advanced imaging services, including MRIs at a specialist's office.
You have been asked to pay a $180 copayment for a shoulder MRI. A shoulder MRI 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 reduce
the copayment for a magnetic resonance imaging (MRI) of the shoulder provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
13, 2021. We also decided that the Plan does not have to waive the copayment and coinsurance for a specialist 
office visit and methylprednisolone injection provided on September 30, 2021. 
 
 
 You asked the Plan to waive the copayments and coinsurance for the laboratory services, specialist office visit, 
and injection. You say that you are retired on limited income and you should not be responsible for any 
copayments. The Plan denied your request. The Plan says the correct copayments and coinsurance were 
applied. 
 
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 $20 
copayment per visit for laboratory tests. 
 
Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit. 
 
Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B drugs, including 
injectable drugs. 
 
You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been 
asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $1.16 for the injection, which is 20% of the allowed amount ($5.80 allowed x 20% coinsurance = $1.16). 
The injection falls within the Medicare Part B Prescription Drugs 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 laboratory services provided on September 13, 2021. We also decided that the Plan 
does not have to waive the copayment and coinsurance for a specialist office visit and methylprednisolone 
injection provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inspan stabilization device. 
 
You asked the Plan to pre-approve an Inspan stabilization device. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says the requested device is unproven 
and not medically necessary. 
 
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 an Inspan stabilization device. Our 
reviewer says that an Inspan stabilization device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found an Inspan device is experimental in spine surgery. More research is needed 
to show safety and efficacy. 
 
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 Inspan stabilization device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Inspan stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth 
visit provided on October 19, 2021. We also decided that the Plan does not have to waive the copayment for a 
specialist telehealth visit provided on October 19, 2021. 
 
You asked the Plan to waive the copayments for the PCP and specialist telehealth visits. You say that you were 
charged for two doctors on the same day for office visits when they should be telehealth visits. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each visit with your PCP, including telehealth services. 
 
Your contract with the Plan clearly says that you must pay a $40 copayment for each visit with a specialist, 
including telehealth services. 
 
You have been asked to pay a $10 copayment for the PCP telehealth visit and a $40 copayment for the 
specialist telehealth visit. The PCP and specialist telehealth 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 a primary care physician (PCP) telehealth visit provided on October 19, 2021. We also decided that the Plan 
does not have to waive the copayment for a specialist telehealth visit provided on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on September 26, 2021.
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 and 70496.
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 70540 is a column II code to column I code 70496. 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 the computed tomography (CT) of the head or brain (70450) provided on September 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied 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 $40 
copay per a visit for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copay per a visit for the physical therapy. This service falls 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 
the physical therapy provided on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
ophthalmic medications. The enrollee had stable vital signs and her lungs were clear. The enrollee does not 
require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 31, 2021, through August 5, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were not aware there would be a copayment. The Plan denied your request. The Plan says the cost share was applied 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 copay per each day one through seven for inpatient hospital care and $90 for emergency room care. You have been asked to pay a $250 copay per each day one through seven for the inpatient hospital care and a $90 copay for the emergency room care. 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 on July 31, 2021, through August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck pain. She 
underwent cervical fusion in 2009 and had RFA of the cervical medial branches in August of 2019. The last 
RFA was performed greater than two years ago; therefore, she needs repeat diagnostic blocks before repeat 
RFA. The services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on September 12, 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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific 
criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of invasive 
adenocarcinoma of the rectum, diagnosed in September of 2020. The documentation does not support that the 
enrollee had recurrent, relapsed, refractory, metastatic, or advanced solid tumor. The documentation does not 
support that the enrollee was untreated for the primary cancer being tested or was not responding to treatment. 
The testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 testing rendered on September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88304) rendered by the out-ofnetwork
(OON) provider on October 6, 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 laboratory service (88304) rendered by the out-of-network (OON) provider on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 28, 2021.
You asked the Plan to pay for the testing services. You say that the services were provided in good faith with the expectation of payment. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records do not show that the specimen was obtained at the independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), complete maxillary denture
(D5110), and complete mandibular denture (D5120) provided on August 11, 2021.
You asked the Plan to pay for the panoramic x-ray, complete maxillary denture, and complete mandibular
denture. You say that the staffing assistant at the provider's office contacted the Plan and told you that dentures
would be covered. The Plan denied your request. The Plan says these services are not covered expenses under
your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify
benefits and provider eligibility.
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
panoramic x-ray (D0330), complete maxillary denture (D5110), and complete mandibular denture (D5120)
provided on August 11, 2021.