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

 
We decided that the Plan does not have to pay for a home visit provided on August 11, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration, natural teeth - resorbable 
barrier per site for tooth #6. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says D4266 is only supposed to be used for natural teeth only. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that information 
included was a panoramic x-ray, clinical note documentation, and an American Dental Association Claim form 
that requests approval for extraction of tooth #6. D4266 for tooth #6 is not medically necessary because tooth 
#6 is to be extracted per the documentation. D4226 is associated this a natural tooth. Since there will not be a 
natural tooth in #6 area, this procedure is not reasonable. There are other procedure codes that are more 
applicable that does not pertain to a natural tooth, but an area of the mouth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve guided tissue regeneration, natural teeth - resorbable barrier per site for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) and the periodic oral 
evaluation (D0120) provided on September 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 cleaning (D1110) and the periodic 
oral evaluation (D0120) provided on September 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 08, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring provided on September 20, 
2023. 
 
You asked the Plan to pay for remote physiologic monitoring. You say that the services were medically 
necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 remote physiologic monitoring provided on September 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 an office visit provided on September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and chemical cauterization 
of granulation tissue provided on February 02, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and chemical cauterization of granulation tissue. 
You say that these services were medically necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care, and chemical cauterization of granulation tissue provided on February 
02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee's disease is growing diffusely and 
rapidly outside of their chest necessitating a response to second-line therapy to save their life. The Plan denied 
your request. The Plan says Medicare drug references do not support the use of Keytruda in combination with 
Abraxane and carboplatin for previously treated metastatic non-squamous non-small cell lung cancer.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Keytruda. Our reviewer says that 
treatment with Keytruda is not medically reasonable and necessary in this case. Our physician reviewer found 
the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued SNF care.  
 
You asked the Plan to pay for continued SNF care. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says you are covered for up to 100 days each benefit period for inpatient services 
in a SNF, in accordance Medicare Guidelines for Skilled Nursing Facility, once you have reached this limit, 
you are no longer eligible for coverage. The last covered day for inpatient skilled care was 07/04/2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 16, 2023, through 
April 20, 2023, and May 1, 2023, through July 5, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
periapical first x-ray (D0220) provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that your crown came off and you could not eat or 
drink. This provider was the only one available.   The Plan denied your request. The Plan says 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 problem focused limited oral evaluation (D0140) and periapical first x-ray (D0220) provided on 
September 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital observation 
provided on October 13, 2023. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you feel that 
the copayment should be waived because you called customer care on October 16, 2023 and was given 
misinformation. 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 $400 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $400 copayment for the outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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 the outpatient hospital observation provided on October 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement of a crown (D2920) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot control when your crown falls off 
and this procedure should be covered again. 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 December 14, 2022. 
Therefore, we decided that the Plan does not have to pay for the re-cement of a crown (D2920) provided on 
July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 21, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay a $35 
copay each time you go to see the specialist. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 27, 2023, to July 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 an office visit provided on June 27, 2023, to July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided on October 10, 2023. 
 
You asked the Plan to pay for electrical stimulation. The Plan denied your request. The Plan says the Plan only 
covers manual manipulation of the spine to correct subluxation. Other services performed by a chiropractor are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation provided on October 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and the dental 
cleaning (D1110) provided on August 31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 periodic oral evaluation (D0120) and the 
dental cleaning (D1110) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided on September 8, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on September 
30, 2023. 
 
You asked the Plan to pay for chronic care management services. You say that these services were medically 
necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 chronic care management services provided on September 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided on July 23, 2023, 
to August 02, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you are dissatisfied with this 
stay, you were there because they didnt do what they needed to do for you. 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 $289 
copayment for inpatient hospital care.  
You have been asked to pay a $289 copayment for an inpatient 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. You have been asked to pay a total of $1,734 for the inpatient hospital stay ($289 copayment x 6 days = 
$1,734). You have not been charged for the day you were discharged. Therefore, we decided that the Plan does 
not have to waive the copayment for an inpatient stay provided on July 23, 2023, to August 02, 2023.