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

 
We decided that the Plan does not have to pay for combined connective tissue and pedicle graft, per tooth 
(D4276) x4 and frenulectomy (D7960) provided on July 14, 2020. 
 
You asked the Plan to pay for dental services. You say that you were unaware these services were not covered. 
The Plan denied your request. The Plan says this service is not covered under your 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. Combined connective tissue 
and pedicle graft, per tooth (D4276) and frenulectomy (D7960) are not covered under the Plans dental 
services. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4276 and D7960 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
combined connective tissue and pedicle graft, per tooth (D4276) x4 and frenulectomy (D7960) provided on 
July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated abutment  includes modification and 
placement (D6056) and abutment supported retainer for porcelain fused to metal FPD (high noble metal) 
(D6069) provided on June 15, 2022. 
 
You asked the Plan to pay for dental services. You say that you called to verify coverage and were told the 
services would be covered; therefore, should not have to pay the billed amount. The Plan denied your request. 
The Plan says these services are not covered under your 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. Prefabricated abutment  
includes modification and placement (D6056) and abutment supported retainer for porcelain fused to metal 
FPD (high noble metal) (D6069) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6056 and D6069 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
prefabricated abutment  includes modification and placement (D6056) and abutment supported retainer for 
porcelain fused to metal FPD (high noble metal) (D6069) provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on November 17, 2022. 
 
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 a covered benefit.  
 
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 the office visit (99203) provided on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 09, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on November 09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral breast reduction.  
 
You asked the Plan to pre-approve a bilateral breast reduction. You say that a bilateral breast reduction is 
medically necessary. The Plan denied your request. The Plan says the submitted clinical information does not 
indicate that the member has tried and failed conservative management, or has skin changes refractory to 
medical management, or has failed 6 months of physical therapy. The clinical information does not state that 
active endocrine or metabolic processes have been ruled out. 
 
The Plan must follow Medicare rules. Medicare rules say that breast reduction is the surgical reshaping of the 
breasts to reduce, or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve 
appearance is not a Medicare benefit.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral breast reduction. Our 
reviewer says that the requested bilateral breast reduction is not considered medically necessary in this case. 
Our reviewer found that the Medicare LCD enumerates the conditions and limitations under which coverage is 
available for the requested service. The provided records in this case do not indicate that the enrollee has tried 
and failed conservative management for her pain or has skin changes refractory to medical management or has 
failed six months of physical therapy for the back pain. The clinical information does not state that active 
endocrine or metabolic processes have been ruled out as required by the Medicare LCD L39051, Cosmetic and 
Reconstructive Surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bilateral breast reduction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral breast reduction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs offloading orthotics that are 
necessary to prevent ulceration and ultimately amputation. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
January 25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed an 
ambulance transport due to the medication that was taken. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 the 
ambulance transportation provided on January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 16, 2022, through July 19, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
copayment. 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 $290 
copayment for each Medicare-covered day, for days 1 to 7 and a $0 copayment for each additional day of the 
inpatient stay.  
 
 You have been asked to pay a $290 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $580 ($290 copayment x 2 days = $580). You have not been charged for any 
additional days. 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 copayment for the inpatient hospital stay provided from July 16, 2022, through July 
19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 28, 2022, billed with 
code 81455. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using CPT 
code 81479 on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with single panel code 
81479, as required. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on July 28, 2022, billed with code 81455.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on 
November 30, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there was no prior-authorization requested. 
 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 subsequent nursing facility care services provided 
on November 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 01, 2022. 
 
You asked the Plan to pay for office visit. You say that you disagree with the plans decision to deny payment 
of the claim submission. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 01, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 23, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was not on hospice during this 
period. 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 inpatient hospital care provided from August 23, 2022, to 
August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services provided on January 20, 2023. 
 
You asked the Plan to pay for blood bank physician services. You say that you thought you were covered to see 
this doctor. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for blood bank physician 
services provided on January 20, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the computed tomography (CT), thorax, diagnostic; without 
contrast material (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that you would like reconsideration based on the 
records submitted.  The Plan denied your request. The Plan says that the requested CT scan is not medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our physician reviewer 
found the follow-up chest CT is reasonable to assure there is no progression of the apical fibrotic disease and 
the associated nodules. A chest x-ray alone is inadequate follow-up for these abnormalities; therefore, the CT 
scan is 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the computed tomography (CT), thorax, diagnostic; without contrast material (71250).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each remdesivir injection and drug 
administration provided on December 21, 2022, to December 24, 2022. 
 
You asked the Plan to waive the coinsurance for each remdesivir injection and drug administration. You say 
that you were told this would be totally 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for each remdesivir injection and drug administration. This 
item/service falls within the in-network Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for each remdesivir injection and drug administration provided on December 21, 
2022, to December 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 03, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told there 
would not be a copayment. 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 $50 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
in-network 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 specialist office visit provided on January 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support necessity for admission to an IRF. No current 
medical complexity. The complexity of the enrollee's nursing, rehabilitation, and medical, needs (combined 
complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to 
rehabilitative care. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), 
the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in an SNF. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy evaluation provided on November 23, 
2022, to December 28, 2022. 
 
You asked the Plan to pay for occupational therapy evaluation. You say that you feel you should not have to 
pay this service, you did not know who you were being referred to. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for occupational therapy 
evaluation provided on November 23, 2022, to December 28, 2022.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support necessity for admission to an IRF. No current 
medical complexity. The complexity of the enrollee's nursing, rehabilitation, and medical, needs (combined 
complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), 
the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in an SNF 
or in-home with 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.