Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 12, 2022, to 
May 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $295 
copayment each day for days 1 to 6 for Medicare-covered hospital care each time you are admitted. $0 
copayment for additional Medicare-covered days. Includes inpatient acute, inpatient rehabilitation, long-term 
care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are 
formally admitted to the hospital with a doctors order. The day before you are discharged is your last inpatient 
day. For days 1-6 there is a $295 copayment. 6 x $295 = $1,770. Therefore, results in the total cost sharing 
amount of $1,770. 
 You have been asked to pay a $295 copayment each day for inpatient hospital stay. This item/service falls 
within the Inpatient hospital care 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 
inpatient hospital stay on May 12, 2022, to May 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on November 20, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you were told you didn't owe anything. 
The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 November 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on November 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) (64624) 
provided on February 17, 2022. 
 
You asked the Plan to pay for the genicular nerve RFA. You say that the documentation supports the medical 
necessity provided to the enrollee. The Plan denied your request. The Plan says genicular nerve ablation is 
considered investigational and not medically necessary for the treatment of chronic knee pain. 
 
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 pay for the genicular nerve RFA. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of RFA of the genicular nerves to treat post-operative total knee arthroplasty 
related pain is still being studied. Our reviewer also found that it is considered experimental/investigational. 
 
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 genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pay for the genicular nerve radiofrequency ablation (RFA) (64624) provided on February 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized knee and vacuum socket. 
 
You asked the Plan to pre-approve a computerized knee and vacuum socket. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a prothesis additions are only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computerized knee and vacuum 
socket. Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found you have been using a K1 knee with manual lock. The 
requested items exceed your medical need as it has deluxe features that are not medically necessary. There are 
19 programmable modes including a Golf mode which do not serve a primary medical need. The device has 
features such as remote data capture and prosthetist app monitoring which also exceed your medical and 
functional needs. Furthermore, the documentation does not support that you require a microprocessor knee over 
a mechanical knee. Therefore, you do not meet criteria for the requested items. 
 
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 computerized knee and vacuum socket have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized knee and vacuum socket.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional facet joint block (64495). 
 
You asked the Plan to pre-approve an additional facet joint block. You say that you need these services. The 
Plan denied your request. The Plan says only two joints are allowed to be injected per session. The Plan also 
says the third injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an additional facet joint block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional facet joint block (64495).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the self-administered drugs provided from 
July 22, 2022, through July 29, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under your 
contractual policy or by Medicare. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to issue reimbursement for the self-
administered drugs provided from July 22, 2022, through July 29, 2022.  Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2790) provided by an out-of-network provider 
on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that crowns are only 
covered once every five years. 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 October 23, 2017. 
Therefore, we decided that the Plan does not have to pay for the crown (D2790) provided by an out-of-network 
provider on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional tooth to existing partial denture (D5650) 
and an additional clasp to existing partial denture (D5660) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you had a root canal that failed. You say 
that you no longer can wear your partial. 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 February 24, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an additional tooth to existing partial denture 
(D5650) and an additional clasp to existing partial denture (D5660) provided by a participating provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on July 25, 2022, 
to July 27, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $120 
copayment for Medicare-covered emergency room visits. Emergency care refers to services that are furnished 
by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition. There were 3 visits. 3 x $120 = $360. Therefore, results in the total cost sharing amount of $360. 
 
 
 
 
 
 You have been asked to pay a $120 copayment for each emergency room service. This item/service falls within 
the Emergency room 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 emergency 
room services on July 25, 2022, to July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the service is 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 
dental services.
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 from November 19, 2022, forward. 
 
You asked the Plan to pre-approve IRF care from November 19, 2022, forward. You say that the continued 
admission to an IRF is medically necessary. The Plan denied your request. The Plan says the continued 
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 from November 19, 2022, 
forward. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary 
based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the documentation does support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation 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 IRF care from November 19, 2022, forward have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services from November 19, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0143) provided on June 20, 2022. 
 
You asked the Plan to pay for the walker. You say that the walker was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0143 is not supported in the medical record. Specifically, the code billed was for a 
new walker, records show this is for a replacement. Based on this information, we decided that Medicare rules 
for coverage of the walker have not been met. Therefore, we decided that the Plan does not have to pay for a 
walker (E0143) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 January 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2752)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213), and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214). 
 
You asked the Plan to pre-approve the maxillary partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5213), and mandibular partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). The 
Plan denied your request. The Plan says these services are not covered under the benefit package. 
 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 partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5213), and mandibular partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plaque removal (D4346) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 
plaque removal (D4346)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the delivery and setup fee for the durable medical equipment 
you purchased on May 26, 2022. 
 
You asked the Plan to pay for the delivery and setup fee. You say that you would like to be reimbursed for this 
expense. The Plan denied your request. The Plan says delivery and setup fees are not covered. The Plan must 
follow Medicare rules. Medicare rules say that Medicare does not pay for delivery and setup fees. Therefore, 
we decided that the Plan does not have to pay for the delivery and setup fee for the durable medical equipment 
you purchased on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 22, 24, 25 
(D6740), and retainer crown - porcelain/ceramic tooth #23 (D6245). 
 
You asked the Plan to pre-approve the retainer crown - porcelain/ceramic tooth #'s 22, 24, 25 (D6740), and 
retainer crown - porcelain/ceramic tooth #23 (D6245). You say that you are aware of the additional dental 
procedures considered to be more than what insurance would cover. You say you would like this to be 
considered as a special case exception since the filling came off and was replaced with the crown. The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
retainer crown - porcelain/ceramic tooth #'s 22, 24, 25 (D6740), and retainer crown - porcelain/ceramic tooth 
#23 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure is medically necessary and the most 
effective treatment. The Plan denied your request. The Plan says this procedure is unproven with insufficient 
evidence of efficacy. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement microprocessor knee component. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is limited by her current 
knee. The Plan denied your request. The Plan says the request exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
The file shows that an OSSUR Power Knee was requested. We looked at the file and Medicare rules. The 
enrollee currently has an OSSUR RHEO Knee 3. The records do not show a change in physiological condition 
or irreparable wear of the device. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
replacement microprocessor knee component.