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

 
We decided that the Plan does not have to waive the deductible for an office visit, an EKG, and laboratory 
services provided on August 22, 2022. 
 You asked the Plan to waive the deductible for the office visit, EKG, and lab services. You say that you did not 
know the provider was out-of-network. 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 there is a $1,000 
deductible which applies to certain items and services. The contract says that the deductible applies to out-of-
network (OON) office visits and OON outpatient diagnostic tests and services. Your contract also says that you 
must pay 40% coinsurance after your $1,000 deductible is met for OON Medicare-covered primary care 
services, OON Medicare-covered diagnostic procedures, including an EKG, and OON Medicare-covered 
laboratory services 
 
The items or services you asked the Plan to waive the deductible for falls within the physician/practitioner 
services and outpatient diagnostic tests benefit categories. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible for OON office visits and outpatient diagnostic tests 
and services. This cost sharing is a contractual obligation that has not yet been met. Therefore, we decided that 
the Plan does not have to waive the deductible for the office visit, EKG, and laboratory services provided on 
August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that your current facility is shutting down and 
this new facility is close to your home. The Plan denied your request. The Plan says network providers are 
available to render necessary care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services (99239), provided on December 3, 
2020, through December 4, 2020. 
 
You asked the Plan to pay for the hospital services. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollee was incarcerated on the date of service. 
 The Plan must follow Medicare rules. Medicare rules say that a state or local government that has custody of a 
Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and 
services unless the State can demonstrate certain requirements are met and the claim is billed with a modifier or 
condition code to indicate the requirements are met.  
 
We looked at the file and Medicare rules. The record indicates that the enrollee was incarcerated at the time of 
service, but there is no documentation that the State would require the enrollee to pay for healthcare services. 
Based on this information, we decided that Medicare rules for coverage of the observation care have not been 
met. 
 Therefore, we decided that the Plan does not have to pay for the hospital services (99239), provided on 
December 3, 2020, through December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary visit (99336) provided on November 14, 2022. 
 
You asked the Plan to pay for domiciliary visit (99336). You say that the service was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary visit (99336) 
provided on November 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisolone. 
 
You asked the Plan to pre-approve Methylprednisolone. You say that the albuterol inhaler and nebulizer does 
not control and manage the enrollees symptoms alone. You also say the enrollee tried and failed Symbicort. 
The Plan denied your request. The Plan says Medicare Part B is not responsible for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methylprednisolone.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) for tooth 
#2. 
 
You asked the Plan to pre-approve the dental services. You say that your crown fell out. 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 December 9, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up 
(D2950) for tooth #2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) provided on October 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are being charged $240.00 for the visit that was 
supposed to be free of charge according to your coverage. You do not understand why the doctor's office did 
not ask for authorization. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99204) provided on 
October 24, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal impacted cerumen using irrigation/lavage, unilateral 
rendered on September 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was denied appropriately because an anatomical modifier was not appended. 
 
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 69209 is "Removal impacted cerumen using 
irrigation/lavage, unilateral." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider remittance form includes CPT 69209 which is a unilateral code with no anatomical modifier. In this case, an appropriate 
modifier would be appended to support service billed. In this case, service was incorrectly billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for removal impacted cerumen using irrigation/lavage, unilateral rendered on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration-resorbable barrier, per site 
(D4266), a bone replacement graft for ridge preservation-per site (D7953), and surgical access to an implant 
body (second stage implant surgery) (D6011). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided 
tissue regeneration-resorbable barrier, per site (D4266), a bone replacement graft for ridge preservation-per site 
(D7953), and surgical access to an implant body (second stage implant surgery) (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures to be rendered by the out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental items from an out-of-network provider are not 
covered by your supplemental benefits. There are in-network providers available to render the requested items.  
 
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 are requesting dental items from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items are not covered under this benefit when received from an out-
of-network provider. Therefore, we decided that the Plan does not have to pre-approve dentures to be rendered 
by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care and related services provided from 
September 24, 2022, through September 29, 2022. 
 
You asked the Plan to pay for subsequent hospital care and related services. You say that  The Plan denied your 
request. The Plan says Original Medicare is responsible for payment.  
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 September 8, 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 subsequent hospital 
care and related services provided from September 24, 2022, through September 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care and Medicare Part B 
prescription drugs 
 
You asked the Plan to waive the cost share for inpatient hospital care and Medicare Part B prescription drugs. 
You say that you disagree with the cost share. 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 $290 
copayment per day for days 1-5 for inpatient hospital care and a 20% coinsurance for Medicare Part B 
prescription drugs.  
 
You have been asked to pay a $290 copayment per day for days 1-5 for inpatient hospital care and a 20% 
coinsurance for Medicare Part B prescription drugs. The total amount for inpatient care is $1,450 ($290 x 5 
days = $1,450). The total allowed amount for the prescription drugs is $11,949.25. The total amount you are being asked to pay is $2,310.49, which is less than your 20% coinsurance amount of $2,389.85 ($11,949.25 x 
20% = $2,389.85). The total amount you are being asked to pay for all services is $3,760.49 ($1,450 + 
$2,310.49 = $3,760.49). This item/service falls within the inpatient hospital care and 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 cost share for inpatient hospital care 
and Medicare Part B prescription drugs
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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 did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 03, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider has no prior 
knowledge of which patients he will be required to see. You also say that since your company has an exclusive 
contract with the nursing facility, your doctors are the only providers who will treat the patients. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve a complete maxillary denture, and a partial mandibular denture. You say 
that you were unaware that this was not a covered benefit. The Plan denied your request. The Plan says the 
requested dentures are not a covered benefit. 
 
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 
complete maxillary denture (D5110), and a partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and lenses (V2100) provided on 
November 7, 2022. 
 You asked the Plan to pay for the routine eyewear. You say that your plan covers up to $100 for eyeglasses. 
The Plan denied your request. The Plan says vision benefits cannot be combined with any other in-store 
benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan's supplemental vision benefits cannot be combined with any other in-store discounts. 
 
We looked at the file and the Plan's rules. In this case the routine eyewear was purchased using a store 
discount. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and 
lenses (V2100) provided on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that you need a faster wheelchair to 
carry your groceries and cross the street safety. The Plan denied your request. The Plan says that the requested 
wheelchair is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the requested power scooter is medically 
necessary. The Plan denied your request. The Plan says that a transport chair and a 4-wheel walker was 
recommended. 
 
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 patients 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 the power scooter. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that based on the medical records 
provided there is no documentation that the requested power scooter is medically reasonable and necessary. 
The provided records do not document that a home assessment has been performed which shows that your 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the 
scooter.  
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.