Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a retainer crown - porcelain fused to high 
noble metal (D6750), pontic - porcelain fused to high noble metal (D6240), core buildup, including any pins 
when required (D2950), and post and core in addition to crown, indirectly fabricated (D2952) provided on 
December 27, 2022. You asked the Plan to waive the copayments for the retainer crown - porcelain, pontic - porcelain, core buildup, 
and post and core services. You say that the provider has not gotten paid for the claim. You also say that you 
and the provider have called but were given the run around. 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 enrollees must pay a $480 
copayment for a retainer crown - porcelain fused to high noble metal (D6750), a $470 copayment for pontic - 
porcelain fused to high noble metal (D6240), a $95 copayment for the core buildup, including any pins when 
required (D2950), and a $105 copayment for the post and core in addition to crown, indirectly fabricated 
(D2952). 
 
You have been asked to pay the following copayments, $480 for each of the retainer crowns - porcelain, $470 
for each of the pontic - porcelain, $85 for the core buildup, and $105 for the post and core services. These 
services fall within the dental 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 copayments for a 
retainer crown - porcelain fused to high noble metal (D6750 x2), pontic - porcelain fused to high noble metal 
(D6240 x2), core buildup, including any pins when required (D2950), and post and core in addition to crown, 
indirectly fabricated (D2952) provided on December 27, 2022.  
 
Your complaint about the provider not being paid and given the run around is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
November 9, 2022, through November 30, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided on November 9, 2022, 
through November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a re-cement or re-bond crown (D2920), 
and re-cement or re-bond fixed partial denture (D6930 x2), provided on July 13, 2022, to January 19, 2023. 
 
You asked the Plan to waive the copayments for the re-cement or re-bond crown and re-cement or re-bond 
fixed partial denture. You say that you are confused on why some things you have to pay more out-of-pocket 
for than others. 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 $10 
copayment for a re-recement or re-bond crown (D2920), and a $64 copayment for re-cement or re-bond fixed 
partial denture (D6930). 
 
You have been asked to pay $10 copayment for the re-cement or re-bond crown, and a $64 copayment for each 
re-cement or re-bond fixed partial denture. These services fall within the dental 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 copayments for a re-cement or re-bond crown (D2920), and re-cement or 
re-bond fixed partial denture (D6930 x2), provided on July 13, 2022, to January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device.. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 a CardioMEMS device.. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
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 CardioMEMS device. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. The Plan denied your request. The Plan 
says  a lumbar epidural steroid injection is not medically necessary.   
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 a lumbar epidural steroid injection. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that a lumbar 
epidural steroid injection will not address the enrollee's buttock pain post the coccygectomy. However, a caudal 
epidural injection or a ganglion impar block are more commonly used for these interventions. Therefore, the 
requested procedure is not medically 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 lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 14, 2023. 
 
You asked the Plan to pay for a home visit. You say that it is the responsibility of the facility to obtain prior 
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 home visit provided on 
February 14, 2023.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. The enrollee 
was admitted for congestive heart failure and cellulitis. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for emergency care and Medicare Part B 
prescription drugs provided on April 20, 2022, to April 21, 2022. 
 
You asked the Plan to waive the cost share for emergency 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 $90 
copayment for emergency care and a 20% coinsurance for Medicare Part B prescription drugs.  
 
 You have been asked to pay a $90 copayment for emergency care and a 20% coinsurance for Medicare Part B 
prescription drugs. The total allowed amount for the prescription drugs is $269.50. You are being asked to pay 
$53.90 ($269.50 x 20% = $53.90). This item/service falls within the emergency 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 emergency care and 
Medicare Part B prescription drugs provided on April 20, 2022, to April 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from October 2, 2021, to October 
27, 2021. 
 You asked the Plan to pay for home health care. You say that you intended to file the RAP by the deadline, but 
a significant even occurred that prevented you from doing so. The Plan denied your request. The Plan says the 
NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 2, 2021. The NOA was not received by the Plan until December 
27, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from October 2, 2021, to October 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary to provide the 
enrollee with the therapists needed to help the enrollee improve. The Plan denied your request. The Plan says 
the enrollee does not meet the coverage criteria for the requested extended skilled nursing facility care.  
 
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 the enrollee is unable to make material gains in response to daily skilled therapy. 
Therefore, the services cannot be approved at this time. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says your doctor asked us to appeal the denial of an injection in your knee, Euflexxa for knee 
pain. We reviewed the records provided. You have tried pain medication, steroid injections, and exercise for 
your knee pain without them helping. We still cannot approve. This medication is not a preferred medication. 
We do not see that you have tried a preferred medication. We do not see where you cannot take a preferred 
medication. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has not trialed a preferred 
viscosupplemental treatment such as Orthovisc or Synvisc.  Step therapy, as outlined by the plan, requires that 
one of these be trialed first. The documentation does not outline contraindications or reasons these medications 
were not considered or that the plans additional required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee.  Without the support of the documentation, Euflexxa is not approved as 
step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor 
(implantable loop recorder - ILR) (33285, C1825). 
 
You asked the Plan to pre-approve the ILR device. You say that the loop recorder is needed for long-term 
surveillance of rhythm. The Plan denied your request. The Plan says the ILR device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that n ILR is used when syncope is thought to be cardiac-
related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found there is no documentation 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. 
Therefore, the reviewer found that the requested ILR device is not medically reasonable or 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 the ILR device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor (implantable loop recorder - ILR) 
(33285, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Provider Delivered Care Management Service provided 
on November 15, 2021. 
 
You asked the Plan to pay for the Provider Delivered Care Management Service. You say that the service 
should be covered. The Plan denied your request. The Plan says your Plan does not offer this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Services considered not reasonable and necessary , according to the standards of 
Original Medicare are not covered, unless these services are listed by the Plan as a covered service. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Provider Delivered Care Management Service have not been met. Specifically, this is not a 
service Original Medicare covers and your Plan does not offer it either. Therefore, we decided that the Plan 
does not have to pay for the Provider Delivered Care Management Service provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair services for durable medical equipment to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve power wheelchair repairs. You say that this services provided should be 
covered. The Plan denied your request. The Plan says the repair services have been approved with an in-
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 
repair services for durable medical equipment to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails provided on January 10, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the debridement of nails. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not authorized. 
 
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 debridement of nails provided on January 10, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face mask (A7030) purchased on March 9, 2023, from a 
non-certified Medicare provider. 
 
You asked the Plan to pay for the face mask. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased from a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the face mask (A7030) purchased on 
March 9, 2023, from a non-certified Medicare provider.