Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft. 
 
You asked the Plan to pre-approve allograft. You say that it is medically necessary. The Plan denied your 
request. The Plan says it has not been FDA-approved for the cervical spine and is still unproven for this type of 
procedure. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested allograft would be as safe or better than standard autograft procedures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Infuse allograft 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 allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided superficial radiation therapy (IGRT). 
 
You asked the Plan to pre-approve image guided superficial radiation therapy. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says there is not enough peer 
reviewed data on the safety and effectiveness of the requested procedure to show that this meets the standards 
of good medical practice. 
 
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 image guided superficial radiation 
therapy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found billing for daily IGRT would not be "furnished in 
accordance with accepted standards of medical practice."  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image guided superficial radiation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve image guided superficial radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient fistulogram to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve outpatient fistulogram. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says this provider is out-of-network, and the services 
could be performed in-network. 
 
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 
outpatient fistulogram to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay on March 23, 
2023, to April 5, 2023.  
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that you don't agree with the 
copayment assessed. 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 per day for days 1-6 and $0 copayment per day for each medically necessary covered inpatient stay. 
For the services it's $250 x 6 = $1,500. You were charged the lesser amount of $1,212.29 which is the amount 
needed to reach your annual maximum out-of-pocket cost. Therefore, results in the total cost sharing amount of 
$1,212.29. 
 
You have been asked to pay a $1,212.29 cost share for the 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 cost share for the inpatient 
hospital stay on March 23, 2023, to April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care provided on July 20, 2023. 
 
You asked the Plan to pay for routine foot care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says there is no coverage for any routine foot care, regardless of 
care setting, including but not limited to toenail trimming, nail debridement, and/or callous or corn treatment. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot 
care provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on May 24, 2023. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cannot determine how the enrollee came to the 
serving provider, whether the billed services were actually performed, or that the services were medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 inpatient hospital care have been met. The records show that the Plan made reasonable attempts to obtain medical records from you but did not 
receive any. Without this necessary information, you have not supported that the criteria for coverage have 
been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on May 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurosurgery consult to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the neurosurgery consult. You say that you say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrollee must get their care from network providers 
that are affiliated with the enrollees primary care provider's (PCP) health network. Usually, the plan wont 
cover care from a provider who doesnt work with the health plan and the enrollees PCPs health network. 
 
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 
the neurosurgery consult to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits June 12, 2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits.. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over-
the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve over-the-counter COVID-19 test kits provided on June 
27, 2023. 
 
You asked the Plan to pre-approve over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over-
the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pre-approve over-the-counter 
COVID-19 test kits provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on July 24, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you should not have for the office 
visit. 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. Your 
contract with the Plan says that there is a $200 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $200 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on July 24, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the office visit on July 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
13, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these services and 
the nearest in-network provider is sixty miles away. The Plan denied your request. The Plan says in-network 
providers were available, and the dental services were received from an out-of-network provider and 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. 
 
 
  The record shows you received the requested 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 pay for the dental services provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper implant/abutment supported removeable denture 
(D6110), lower implant/abutment supported removeable denture (D6111) and extractions (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits. Upper implant/abutment supported removeable denture and lower implant/abutment 
supported removeable denture are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 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. Upper implant/abutment supported removeable denture and lower 
implant/abutment supported removeable denture are not covered services Therefore, we decided that the Plan 
does not have to pre-approve upper implant/abutment supported removeable denture (D6110), lower 
implant/abutment supported removeable denture (D6111) and extractions (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an injection and specialist office visit 
provided on June 28, 2023. 
 
You asked the Plan to reduce the cost share for an injection and specialist office visit. You say that you do not 
understand why the cost share for this injection is higher than previous injections. 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 Part B prescription drugs and a $30 copayment for services from a specialist.  You have been asked to pay $1,043.40 coinsurance for an injection and specialist office visit. This total 
includes $1,013.40 coinsurance, which is 20% of the allowed amount for a Medicare Part B drug injection 
($5,067 allowed x 20% = $1,013.40), and a $30 copayment for a specialist visit. The injection falls within the 
Medicare Part B prescription drugs benefit category. The specialist visit falls within the physician/practitioner 
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 reduce the cost share for an injection and specialist 
office visit provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological services provided on March 9, 2023. 
 
You asked the Plan to pay for psychological services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this provider was not certified or eligible.  
 
The Plan must follow Medicare rules. Medicare rules say that the rules say that certain individuals and entities 
frequently attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an 
enrollment application from the individual or entity, the contractor shall deny the application. Licensed 
Professional Counselor (LPC) is among the provider types that are not eligible to enroll in Medicare.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychological services have not been met. Therefore, we decided that the Plan does not have to pay 
for psychological services provided on March 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 24, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are appealing the denied claim with medical 
records. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on December 
24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on February 9, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) and to pay for the pulp vitality tests (D0460), the protective restoration (D2940), 
and the incomplete endodontic therapy (D3332) for tooth #2 provided by an out-of-network provider on June 
14, 2023, and June 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan would cover a complete root 
canal so they should cover a failed root canal. 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. Also, the pulp vitality tests, the protective restoration, and the incomplete endodontic therapy 
are not covered by the 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. 
 
The total amount billed for the limited oral evaluation (D0140) was $175 and the total allowed amount was $35 
leaving a difference of $140 ($175 billed - $35 allowed). The total amount billed for the intraoral radiographic 
image (D0220) was $45 and the total allowed amount was $12 leaving a difference of $33 ($45 billed - $12 
allowed). 
 
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. The 
pulp vitality tests, the protective restoration, and the incomplete endodontic therapy are not covered under the 
Plan's dental benefit. Therefore, we decided that the Plan does not have to pay more for the limited oral 
evaluation (D0140) and the intraoral radiographic image (D0220) and to pay for the pulp vitality tests (D0460), 
the protective restoration (D2940), and the incomplete endodontic therapy (D3332) for tooth #2 provided by an 
out-of-network provider on June 14, 2023, and June 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs received on July 12, 2023. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that the medication was 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 July 12, 2023.  
 
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.