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

 
We decided that the Plan does not have to waive the copayment for office visit on June 10, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each office visit or telehealth visit to other providers. Covered services include medically-
necessary medical care or surgery services furnished in a physicians office, certified ambulatory surgical 
center, hospital outpatient department, or any other location and consultation, diagnosis, and treatment by a 
specialist.  
 
 
 
 
 You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210, D7140), immediate mandibular dentures 
(D5140), immediate maxillary dentures (D5130), and drugs or medicaments dispensed in the office for home 
use (D9630) provided on January 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for extractions (D7210, D7140), immediate mandibular dentures (D5140), immediate maxillary dentures 
(D5130), and drugs or medicaments dispensed in the office for home use (D9630) provided on January 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esketamine (Spravato). 
 
You asked the Plan to pre-approve Spravato. The Plan denied your request. The Plan says there is not enough 
clinical rationale to justify the medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Spravato. Our physician reviewer found 
that the enrollee has a diagnosis of recurrent major depressive disorder. The record indicates that the requested 
drug will be used as monotherapy. The FDA has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The documentation does not support that the requested drug is 
safe and effective and otherwise reasonable and necessary for this enrollee. The elements of the coverage 
criteria are not satisfied.  The requested service cannot be recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spravato have not been met. Therefore, we decided that the Plan does not have 
to pre-approve esketamine (Spravato).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
February 21, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that you did not receive proper 
notice of the enrollee's benefit determination. You say that this caused the claim to be late. You also say that 
the medically necessary services were rendered to the enrollee in good faith. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 14, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge day management (99239) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you fell at home and were admitted to the hospital. 
You say that you need skilled nursing physical therapy to become stable enough to go to the restroom on your 
own. The Plan denied your request. The Plan says your records show your condition does not meet the 
requirements for coverage of skilled nursing facility services according to Chapter 8 of the Medicare Benefit 
Policy Manual. 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 you 
have syncope, congestive heart failure, atrial fibrillation and had a fall with scalp laceration. You received oral 
medications, had stable signs and your lungs were clear. You were at a supervision/stand by assist to contact 
guard assist level for functional mobility including gait to 100 feet with a rolling walker. You also required 
varying assist with activities of daily living skills. You do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in 
a skilled nursing facility (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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on January 20, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that this test was required for you to 
come back to the United States. The Plan denied your request. The Plan says at-home COVID-19 test kits are 
not a covered benefit with your plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits are an OTC item. The Plan does not offer a supplemental benefit covering this service, as 
this is not currently required by Medicare. However, for future purchases, these can be obtained with 
participating providers and covered by Original Medicare when using your Medicare card rather than your Plan 
card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on January 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on June 29, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
interrogation device evaluation. We found no exception that would require the Plan to pay for the interrogation 
device evaluation. The records provided for review do not show that the interrogation device evaluation was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the interrogation device 
evaluation provided on June 29, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Durolane, Monovisc, or Synvisc-One. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our physician reviewer found 
that the enrollee has osteoarthritis of the right knee. The requested medication is a new start. The Plan requires 
a trial of Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. The provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
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 you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with viral encephalitis, 
pneumonia, complicated by seizures, cerebral vascular attack, hematomas, pressure wounds, and multiple drug 
resistant pathogens. The enrollee was treated with a shunt tap, cranioplasty, and mechanical ventilation. Recent 
notes describe the enrollee not tolerating trach collar with oxygen support but requiring additional intravenous 
antibiotics and physical and occupational therapy.  
 The enrollee appears to be more stable and improving on the current treatment regimen and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and appropriate for transfer to a lower level of care. The enrollee is receiving appropriate care at the present 
setting. The enrollee does not require services at the LTACH that are not available at the current facility. 
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2021, to November 4, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says reimbursement for the service was denied because the 
provider doesn't have a contract with Medicare. 
 
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 an office visit provided on May 3, 2021, to 
November 4, 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 a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve a denture. You say that this service should be covered. The Plan denied your 
request. The Plan says a maxillary complete denture (D5110) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary complete denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310), pulp vitality test (D0460), root canal 
obstruction on tooth #3 (D3331), and endodontic therapy on tooth #3 (D3330) provided on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a consultation (D9310), pulp vitality test (D0460), root canal 
obstruction (D3331), and endodontic therapy (D3330) is not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310), pulp vitality test (D0460), root canal obstruction on tooth #3 (D3331), and endodontic 
therapy on tooth #3 (D3330) provided on April 21, 2022.
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 enrollee needs assistance with eating and 
building strength. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
IRF services do not meet the requirements for approval. 
 
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 that the enrollee has functional loss related to chronic disease, recurrent hospital stays, and progressive neurological disease with dementia. Dementia limits the enrollee's capacity for intensive 
rehabilitation. The enrollee does not have complex needs requiring acute hospital-based rehabilitation. The 
enrollee requires standard post-acute rehabilitation and does not require frequent physiatry oversight. Neither 
intensity nor complexity criteria are met. 
 
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 pre-approve second stage implant surgery on tooth #9 and 29 
(D6011). 
 
You asked the Plan to pre-approve implant surgery. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says second stage implant surgery (D6011) is not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
second stage implant surgery on tooth #9 and 29 (D6011).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy treatment provided on 
April 8, 2022. 
 
You asked the Plan to waive the copayment for the radiation treatment. You say that each treatment session 
should only cost a total of $30. 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 $30 
copayment for each radiation therapy service.  
 You have been asked to pay $14.85, which is less than the $30 copayment for the radiation treatment. The 
radiation treatment falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for radiation therapy treatment provided on April 
8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve an evaluation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says this service is not covered by your benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve a comprehensive oral 
evaluation (D0150).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service February 
26, 2022, to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the procedure code in this case is a service 
code only. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service February 26, 2022, to March 25, 2022.