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

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on February 6, 2023, and 
March 28, 2023. 
 
You asked the Plan to pay for a core buildup . You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 core 
buildup (D2950) provided on February 6, 2023, and March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should cover these procedures due to 
your finical hardship. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 5, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported fixed denture for 
edentulous arch  mandibular (D6115). 
 
You asked the Plan to pre-approve the implant /abutment supported fixed denture. You say that you are in a lot 
of pain and are getting an extraction. You also say that you need the implant desperately because you are 
missing the tooth in front. The Plan denied your request. The Plan says the dental implant is not covered under 
your dental 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 an 
implant /abutment supported fixed denture for edentulous arch  mandibular (D6115).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retroperitoneal ultrasound provided on October 27, 2021. 
 You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. 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 a retroperitoneal ultrasound provided on October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from May 18, 2023, through May 23, 2023. 
 
You asked the Plan to pay for IRF care. You say that you do not understand why inpatient rehabilitation 
authorization was denied as your physician said it had been approved The Plan denied your request. The Plan 
says your records do not show to have complicated rehabilitation issues and you do not need to see a 
rehabilitation doctor at least three times a week. Services needed may be provided safely in a lower level of 
care. 
 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 pay for 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from May 18, 2023, 
through May 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CTA scan provided on February 21, 
2023. 
 
You asked the Plan to waive the copayment for a CTA scan. You say that you disagree with the copayment 
applied. 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 $275 
copayment for diagnostic radiological services.  
 
 
  You have been asked to pay a $275 copayment for a CTA scan. This item/service falls within the outpatient 
diagnostic radiological 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 copayment for a CTA scan 
provided on February 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes G0299, Q5005 rendered on February 3, 
2023, through February 7, 2023. 
 You asked the Plan to pay for the procedure codes G0299, Q5005. You say that the services were medically 
necessary. 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 the procedure codes G0299, Q5005 rendered on February 3, 
2023, through February 7, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for future PT visits. 
 
You asked the Plan to waive the copayments for future PT visits. You say that you are unable to work due to 
your current medical condition and cannot afford the PT needed to heal. The Plan denied your request. The 
Plan says the cost sharing will be applied according to the Plan contract. 
 
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 $40 
copayment for each PT visit.  
 
 
  You have been asked to pay a $40 copayment for each PT visit. This item/service falls within the outpatient 
rehabilitation 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 future PT 
visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the imaging is needed due to the enrollee's 
dementia diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records were silent on the presence (or 
absence) of either AD or FTD, let alone both. In such a setting this service would not be considered to be 
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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the service is needed because you have had back pain 
for 30 days. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has chronic right sciatica. 
Physical therapy has been recommended but declined. No red flags such as absent reflex, weakness, or 
evidence of cauda equina syndrome are identified in the records. There are no lumbar spine x-ray reports. The 
medical necessity of the requested MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 1, 2022, 
to September 29, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the PT services provided by an OON provider. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services are no 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 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 physical therapy services provided on 
September 1, 2022, to September 29, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 14, 2022. 
 You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were medically 
necessary. 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 a domiciliary or rest home visit provided on June 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 9, 2023, 
to January 28, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you only spent 20 days in the facility 
and should have $0 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 $0 
copayment for days 1 to 20, a $196 copayment per day for days 21 to 38, and $0 copayment for additional days 
up to 100 for SNF care.  
 You have been asked to pay a $196 copayment for a SNF stay. This item/service falls within the SNF care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from 
January 9, 2023, to January 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is due to symptoms of stomach pain 
and dizziness. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you have refused a prostate biopsy. The 
criteria do not allow for PET/CT as the initial staging procedure of prostate cancer let alone as a test PRIOR to 
a tissue diagnosis of prostate cancer. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monitoring feature for a Positive Air Pressure device 
(E1399, A9279) provided on February 10, 2023. 
 
You asked the Plan to pay for the monitoring feature. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no Medicare benefit or payment to 
DMEPOS suppliers for remote monitoring services. Suppliers must not bill A9279 for remote monitoring 
services. Claims billed for monitoring technologies using other codes such as E1399 will be denied as incorrect 
coding. 
 
We looked at the file and Medicare rules. The billed monitoring feature is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitoring feature have not been 
met. Therefore, we decided that the Plan does not have to pay for a monitoring feature for a Positive Air 
Pressure device (E1399, A9279) provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost sharing for removal of residual tooth roots (cutting 
procedure) (D7250) provided on February 27, 2023. 
 
You asked the Plan waive the cost sharing for the removal of residual tooth roots. You say that the denial 
explanation is not applicable or understandable since there is no other carrier, and you question what the reason 
is. The Plan denied your request. The Plan says the claim processed appropriately. 
 
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 follows Medicare rules. Medicare 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 50% coinsurance for the removal of residual tooth roots after a $50 
deductible. The contract also says that enrollees may be billed by the out-of-network provider for any charged 
amount greater than the payment made by the Plan. 
 
You have been asked to pay a total of $283 for the removal of residual tooth roots service. The Maximum 
Allowable Charge (MAC) for the removal of residual tooth roots was $134. You were asked to pay a $50 
deductible for the residual tooth roots service, leaving $84 remaining due of the MAC. You were then asked to 
pay a 50% coinsurance of that remaining amount due, totaling $42. Because you received services these 
services from an out-of-network provider, you were also held responsible for the amount exceeding the MAC. 
The out-of-network provider billed $325 and the allowed amount of this service is $134.00 ($325 - $134 = 
$191). The $50 deductible, the $42 coinsurance, and the $191 difference between the billed and allowed 
amounts total $283 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 waive the cost sharing for removal of residual tooth 
roots (cutting procedure) (D7250) provided on February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile, and there is every reason to expect that he will 
participate in and benefit from services to include at minimum physical and occupational therapy, nutrition, and 
physician management of ongoing cardiovascular, renal, and ID issues, as well case manager coordination of 
any additional services he might need to make a sustainable return home. In light of the records here presented, 
skilled nursing facility placement would appear wholly inappropriate to meet his needs and get him back to 
prior level of function. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279 and E1399 provided on March 2, 
2023. 
 
You asked the Plan to pay for procedure codes A9279 and E1399. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Additionally, claims billed for monitoring 
technologies using other not otherwise classified (NOC) codes such as E1399 (durable medical equipment, 
miscellaneous) will be denied as incorrect coding. Based on this information, we decided that Medicare rules 
for coverage of procedure codes A9279 and E1399 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes A9279 and E1399 provided on March 2, 2023.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for home health and therapy services provided on February 14, 2023. 
 
You asked the Plan to pay for the home health and therapy services. You say that the enrollee was not on 
hospice on this date. The Plan denied your request. The Plan says that Original Medicare is responsible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded documentation showing that the 
enrollee was on hospice. The included document does not match Medicare records. Current records show that 
the enrollee ended hospice on January 24, 2023. Since the Plan's denial is not substantiated in this case, we 
must find in your favor. Therefore, we decided that the Plan has to pay for home health and therapy services 
provided on February 14, 2023.  
 
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.