Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the dexamethasone sodium phosphate injection 
provided on January 24, 2022. We also decided that the Plan does not have to waive the coinsurance for the 
other drug injections provided on January 14, 2022.  
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you already met your out-of-
pocket maximum for the year. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the dexamethasone sodium phosphate 
injection.  
 
You have been asked to pay 20% coinsurance for the dexamethasone sodium phosphate injection. According to 
Medicare, the injection (J1100) is considered a packaged code and is not separately payable. This code is also 
excluded from the physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance 
for the dexamethasone sodium phosphate injection provided on January 14, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the other drug injections. 
 
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 20% 
coinsurance for Medicare Part B drugs.  
 
The records show that you had not met your out-of-pocket maximum prior to receiving the drug injections on 
January 14, 2022. You have been asked to pay 20% coinsurance for each drug injection. These items/services 
fall within the Medicare Part B 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 coinsurance for 
the other drug injections provided on January 14, 2022. 
 
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 pulp vitality test (D0460) and cone beam CT limited view-
less than one jaw (D0364) provided on November 14, 2022. 
 
You asked the Plan to pay for pulp vitality test and cone beam CT. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 pulp 
vitality test (D0460) and cone beam CT limited view-less than one jaw (D0364) provided on November 14, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
  You asked the Plan to pre-approve additional mileage. You say that you had four stents put in on February 16, 
2023, and have visits set up for February 27, 2023. You also say that the provider you need to see is more than 
50 miles away from you, and you live in a rural area. The Plan denied your request. The Plan says the enrollee 
is requesting to be transported an additional 5 miles for a total of 55 miles. The Plan also says the enrollee's 
benefit only allows 50 miles, this request exceeds the benefit limit, and is not covered by the health plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for single administration implant removal (D6100), intravenous 
moderate (D9243, D9239), osseous surgery (D4261 & D4260) and therapeutic parenteral drugs (D9610) 
provided from June 30, 2022, to August 9, 2022. 
 
You asked the Plan to pay for implant removal, surgery, and therapeutic drugs.. You say that this should be 
covered. The Plan denied your request. The Plan says these are not covered services. 
 
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 single 
administration implant removal (D6100), intravenous moderate (D9243, D9239), osseous surgery (D4261 & 
D4260) and therapeutic parenteral drugs (D9610) provided from June 30, 2022, to August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated knee orthosis. 
 
You asked the Plan to pre-approve knee orthosis. You say that this is medically appropriate to decrease pain 
and improve overall function by correcting the underlying deformity. The Plan denied your request. The Plan 
says the records show the enrollee does not have a new knee injury or objective evidence of joint instability on 
examination. 
 
The Plan follows Medicare rules. Medicare rules state that prefabricated knee orthoses may be covered under 
certain conditions. 
 
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 knee orthosis. Our reviewer says that 
the enrollee does not meet criteria for this item. Our physician reviewer found the enrollee has arthritis in the 
knee. This is a chronic condition with no surgery or recent injury and no instability. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prefabricated knee orthosis.
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 are unable to stand up alone, require 
incontinence care, and are unable to care for yourself without the assistance of others. You also say you need 
continuous care. The Plan denied your request. The Plan says the continuation of SNF services is not medically 
necessary. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. You do not 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital level of care for total knee 
arthroplasty surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this surgery is needed as soon as 
possible. The Plan denied your request. The Plan says this procedure can be done as an ambulatory procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the enrollee does not meet criteria for inpatient hospital level of care. Our physician reviewer found 
the notes did not describe the enrollee as high-risk or with an unstable condition to suggest a need for a higher 
level of care following surgery for this typically ambulatory procedure. There is no expectation that the 
enrollee will likely require 2 or more midnights of inpatient services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital level of care for total knee arthroplasty surgery.
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 services are necessary as the enrollee 
is at high risk for a poor outcome. The Plan denied your request. The Plan says the enrollee does not need the 
multiple intense services provided in this setting. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic on tooth #7, 8, 9, and 10 (D6241) and retainer 
crowns on tooth # 6 and 11 (D6751). 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need the bridge because 
the crown cannot be fixed. The Plan denied your request. The Plan says that the coverage criteria has not been 
met. 
 
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 Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
 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 pontics and retainer crowns. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the Plan criteria 
says that you must be missing only one upper front tooth or only two lower front teeth. There cannot be any 
missing posterior teeth. In this instance, four anterior teeth would be replaced with the bridge, which is not 
allowed under the Plans criteria. There are also numerous missing posterior molar and premolar teeth, which 
again is not allowed under the Plans criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic on tooth #7, 8, 9, and 10 (D6241) and retainer crowns on tooth # 
6 and 11 (D6751).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that you have pain on your neck and head and pain when 
you have movement on the left side. The Plan denied your request. The Plan says you must receive care from a 
network provider.  
 
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 
magnetic resonance imaging (MRI) of the neck to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not need the ambulance transport and are asking for reconsideration of payment. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on October 26, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that we depend on the facility staff to 
verify eligibility and to obtain authorization. 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 a skilled nursing facility 
visit provided on October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement. 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is unproven and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered investigational. 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 the interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-level positive airway pressure (BiPAP) Machine 
(E0470) and humidifier (E0562). 
 
You asked the Plan to pre-approve a BiPAP Machine and humidifier. You say that the items are medically 
necessary. The Plan denied your request. The Plan says your machine showed that you have used it for less 
than 4 hours for 6 nights (7%) within a 90-day period. To qualify for a second BiPAP trial, you must be 
evaluated by your physician to determine the reason you failed the first trial and there must be a repeat sleep 
study performed. 
 
The Plan must follow Medicare rules. Medicare rules say that for a BiPAP to be covered, the criteria listed in 
the Medicare Rules section must be met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a BiPAP Machine and humidifier have not been met. Specifically, you have not had repeat sleep 
study. Therefore, we decided that the Plan does not have to pre-approve a bi-level positive airway pressure 
(BiPAP) Machine (E0470) and humidifier (E0562).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the injections provided on October 17, 2022. We 
also decided that the Plan does not have to waive the copayment for the SPECT scan provided on October 17, 
2022.  
 
You asked the Plan to waive the cost share for the SPECT scan and the injections. You say that you have met 
your out-of-pocket maximum prior to this service. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the injections provided on October 17, 2022.  
 
You have been asked to pay 20% coinsurance for each injection. According to Medicare, an aminophyllin 
injection (J0280) and a regadenoson injection (J2785) are considered packaged codes and are not separately 
payable. These codes are also excluded from the physician's fee schedule. Therefore, we decided that the Plan 
has to waive the coinsurance for the injections provided on October 17, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the SPECT scan provided on 
October 17, 2022. 
 
The record shows your maximum out-of-pocket was not met prior to this service. You have been asked to pay a 
$200 copayment for the SPECT scan. This item/service falls within the outpatient diagnostic testing and 
therapeutic 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 the SPECT scan 
provided on October 17, 2022. 
 
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 CT cone beam scan (D0367) provided on January 9, 2023. 
 
You asked the Plan to pay for CT cone beam scan. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for CT cone 
beam scan (D0367) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for analgesia (D9230), retreatment or previous root canal 
therapy  bicuspid (D3347) and retreatment or previous root canal therapy  molar (D3348) provided on 
November 2, 2022, to December 25, 2022. 
 
You asked the Plan to pay for root canal therapies and analgesia. You say that this should be covered. The Plan 
denied your request. The Plan says analgesia is not a covered service and the root canal therapies are covered at 
50% of the total cost. 
 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 analgesia 
(D9230), retreatment or previous root canal therapy  bicuspid (D3347) and retreatment or previous root canal 
therapy  molar (D3348) provided on November 2, 2022, to December 25, 2022.