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

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 4, 2023. 
 
You asked the Plan to pay for self -administered drugs. You say that that you received a hospital bill and are 
not sure why you have to pay it because you cannot afford it. The Plan denied your request. The Plan says self-
administered drugs do not fall under Medicare 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 pay for self-administered drugs provided 
on January 4, 2023.  
 
Benefits for self -administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. 
 
You asked the Plan to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image 
guidance (fluoroscopy or CT) including arthrography when performed. You say that the requested injection is 
medically necessary. The Plan denied your request. The Plan says the injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an injection procedure for sacroiliac 
joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed 
have been met. There are no medical records provided to determine if Medicare rules have been met. 
Therefore, we decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs received on December 8, 
2022. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 the self-administered drugs 
received on December 8, 2022.  
 
Benefits for the self-administered drugs 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 the enrollee meets IRF criteria and is reasonably 
expected to participate in, and benefit from 15 hours of therapy a week and daily physician oversight. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for a clavicle fracture after a fall. The enrollee's medical 
problems are stable, and 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.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on January 13, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that this should be 
covered. 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 $35 
copayment for Medicare covered vision services.  
 
   
You have been asked to pay a $35 copayment for a medical eye examination. This item/service falls within the 
Medicare covered vision 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 a 
medical eye examination (92014) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 8, 
2022. 
 
You asked the Plan to pay for 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 July 25, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 8, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows facet degenerative joint disease and foraminal 
stenosis. The cause of back pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64629, 64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a CT scan and medical supplies provided on 
January 28, 2021. 
 You asked the Plan to waive the cost share for a CT scan and medical supplies. You say that the cost applied on 
previous claims for the same services were different. 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 20% 
coinsurance for Medicare-covered medical supplies and a $160 copayment for Medicare-covered radiological 
diagnostic services, not including x-rays.  
 
You have been asked to pay a total cost share of $199.78 for a CT scan and medical supplies. This total 
includes $39.78 coinsurance (198.90 allowed x 20% = $39.78) and a $160 copayment. These items/services fall 
within the outpatient diagnostic tests 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 a 
CT scan and medical supplies provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided from January 25, 2023, to 
January 31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your policy covers $3,000 in dental 
benefits. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental services provided from January 
25, 2023, to January 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 21, 2022. 
 You asked the Plan to pay for ambulance services. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure has been cleared 
through the Food and Drug Administration, and the procedure is safe and effective. You say that the procedure 
is medically necessary. The Plan denied your request. The Plan says the service is not clinically effective and 
considered experimental and investigational with unclear source of multifactorial back 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 pre-approve the Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) shows scoliosis and foraminal stenosis, which means 
the cause of back pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
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 enrollee was admitted for rib fractures and surgical management of aortic 
dissection, splenic laceration, small bowel injury and diaphragm rupture after a motor vehicle accident. The 
enrollee's medical problems are stable, and 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. 
 
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 copayments for a CT scan and an injection provided from 
January 23, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayments for a CT scan and an injection. You say that you do not 
understand why you were charged anything for the tests and procedure done prior to the surgery. 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 $250 
copayment for advanced radiological services.  
 
 You have been asked to pay a total copayment of $346.07 for a CT scan and an injection. The total includes 
$96.07 for a CT scan, which is less than the standard $250 copayment, and a $250 copayment for an injection. 
These items/services fall within the outpatient hospital 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 CT scan and an injection provided from January 23, 2023, to January 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on January 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee has Alzheimer's disease and fell. You also say that the emergency medical service determined that the 
enrollee did not need to go to the hospital but instead transported her to her daughter's home. 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 January 30, 2023. 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 ambulance response and treatment with no 
transport provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer (D2962) provided on November 10, 2022. 
 
You asked the Plan to pay for 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 pay for a labial 
veneer (D2962) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2750) and resin-based composites (D2331 
x 2) provided on February 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were misinformed and told that the 
provider was in-network with the Plan. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the crown (D2750) and resin-based 
composites (D2331 x 2) provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on January 24, 2022, by an out-
of-network (OON) provider.  
   
You asked the Plan to pay for the vision services. You say that authorization was not needed. The Plan denied 
your request. The Plan says this provider is out-of-network, and an authorization was not in place. 
 
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 vision services provided on January 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures are broken, and you require a 
new pair. 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 8, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and 
mandibular complete denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction provided on February 08, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary due to your 
radiation treatment causing your tooth to decay. The Plan denied your request. The Plan says this service is not 
a covered benefit under your dental plan. 
 
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 the 
surgical extraction provided on February 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 9, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says for a facility to receive reimbursement for a Medicare 
member, the facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 9, 2023.