Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that this should be covered under your yearly 
physical. The Plan denied your request. The Plan says the copayment applied 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 $225 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $225 copayment for CT scan. CT scans fall 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 CT scan provided on April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #3 and 4 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that if this problem is not treated you will need a root 
canal. The Plan denied your request. The Plan says that there is no evidence of decay or missing crowns to 
support the need for replacements. 
 
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 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 crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the provided x-rays do not show a 
definitive carious lesion around either of the teeth, and a clinical narrative would be necessary to support the 
notion that tooth #4 would need replacement for reason of carious involvement.  Tooth #3 shows no defect on 
the provided x-rays of any kind. Given the provided x-rays as the only documentation supplied to address new crowns for #3 and #4 as well as any core buildups, there would be no necessity found for the requested 
procedures. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a crown on tooth #3 and 4 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathroom remodel for the shower. 
 
You asked the Plan to pre-approve the requested services. You say that you will not be able to bathe yourself 
on a daily basis. The Plan denied your request. The Plan says the request is a convenience and not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The request is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bathroom remodel for the shower.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NovoLog FlexPen. 
 
You asked the Plan to pre-approve NovoLog. You say that the enrollee needs insulin to help control diabetes. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under 
Medicare Part B. 
 
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 a NovoLog FlexPen.  
 
 Benefits for NovoLog 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 27, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this should be covered. The Plan 
denied your request. The Plan says the copayment applied 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests.  
 
You have been asked to pay $10 copayment for lab services. Lab services fall 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 laboratory services provided on April 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transport and ER care provided 
on October 26, 2021. 
 
You asked the Plan to waive the copayments for ambulance transport and ER care. You say that this should be 
covered. The Plan denied your request. The Plan says the copayments applied are 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 $210 
copayment for each covered trip and $85 copayment for each ER visit. 
 
 You have been asked to pay $210 copayment for ambulance transport and $85 copayment for ER care. 
Ambulance transport falls within the Ambulance Services benefit category. ER care falls within the Emergency 
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 copayments for ambulance transport and ER 
care provided on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection provided on March 10, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that you have had these injections in the past 
and never had to pay a copayment before. The Plan denied your request. The Plan says the copayment applied 
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 $275 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 
You have been asked to pay $275 copayment for injection. Injections fall within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 injection provided on March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that this should be covered. The Plan denied 
your request. The Plan says the copayment applied 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 $150 
copayment for all other diagnostic procedures and tests. 
 
You have been asked to pay $150 copayment for MRI. MRIs fall 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 
MRI provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial lower denture. You say that you want the Plan to cover this. The 
Plan denied your request. The Plan says the service at issue 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 a 
partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you have a scheduled urgent surgery. The 
Plan denied your request. The Plan says the request exceeds your benefit limit. 
 
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.  
 
 
 Transportation over 75 miles was requested. We looked at your request, the records in the case file, and the 
rules. Your plan benefit only covers trips up to 75 miles. 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 for routine transportation.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the head or brain (70450). 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee has had neuropsychological testing and 
requires a CT for further evaluation. The Plan denied your request. The Plan says that there is no 
documentation provided to show that the enrollee has a known (diagnosed) problem with memory, and 
therefore this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
requested CT scan is medically necessary and reasonable in this case. Our physician reviewer found the 
generally accepted standard of practice in the evaluation of dementia or similar memory disorders is to perform 
a neuroimaging study to rule out a structural etiology for symptoms. In this case, the enrollee is noted to have 
memory problems and is noted to have a likely contraindication to the performance of magnetic resonance 
imaging (MRI) due to having a gastric simulator device. Ultimately, this request would be consistent with 
standards of care and therefore would fall within the classification of being reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) of the head or brain (70450).  
 
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 waive the copayment for an office visit and an x-ray provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for an office visit and an x-ray. You say that you were given wrong 
information by the doctor so it should be covered. The Plan denied your request. The Plan says the copayments 
applied are 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 $15 
copayment for x-rays and a $35 copayment for a specialist office visit.  
 You have been asked to pay $50 copayment for an office visit and an x-ray. X-rays fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The office visit falls within the 
Physician/Practitioner Services, Including Doctors 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 an office visit and an x-ray provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant removal on tooth #29, 30, and 31 (D6100). 
 
You asked the Plan to pre-approve implant removal. You say that you have an infection and need to have the 
implants removed. The Plan denied your request. The Plan says implant removal (D6100) 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 
implant removal on tooth #29, 30, and 31 (D6100).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that the enrollee was non-therapeutic on Warfarin, and had 
bleeding on Eliquis. The Plan denied your request. The Plan says Xarelto is a self-administered drug, and does 
not fall under Part B coverage. 
 
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 Xarelto.  
 
Benefits for Xarelto 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: 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 you were isolated for COVID-19 and have not yet 
received adequate rehab for your condition. Your provider is recommending IRF care. The Plan denied your 
request. The Plan says the criteria for admission to an IRF are not met in this case. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible for this 
copayment. The Plan denied your request. The Plan says the copayment has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $185 for 
a CT scan. However, you have only been asked to pay $119.41 which is less than the $185 copayment. 
 
You have been asked to pay $119.41 for a CT scan. For this procedure, the provider billed $1709. The Plans 
allowance was $119.41, which is less than your $185 copayment. A CT scan 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 a CT scan provided on March 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation/inpatient hospital care provided on September 
14, 2021. 
 
You asked the Plan to pay for observation/inpatient hospital care. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for observation/inpatient hospital care provided on September 
14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to appeal the denial of 
the authorization. The Plan denied your request. The Plan says the denial of the LTACH admission was 
appropriate given the clinical scenario. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower level of care. 
 
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 LTACH 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. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met in 
this case. The enrollee's needs can be met in a less intensive setting. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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.