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

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from February 1, 
2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that the additional stay was authorized by 
your physician. 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 for days 21 to 39 and $0 copayment for days 40 to 100 for SNF 
care.  
 
You have been asked to pay a $3,335 copayment for a SNF visit. This amount is less than the standard 
copayment because your maximum out-of-pocket was met with the processing of this claim. 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 visit 
provided from February 1, 2023, to February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), bitewings 
(D0274), and a cleaning (D1110) provided by an out-of-network provider on February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan and they verified that you 
had out-of-network benefits and they called the dentist office to confirm it. 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. Also, it was verified that the records indicate you or the enrollee did contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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 the enrollee 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 a comprehensive oral evaluation (D0150), bitewings (D0274), and a cleaning (D1110) provided 
by an out-of-network provider on February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on February 21, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the Plan 
applied the full cost as a copayment so your secondary insurance will deny the claim. 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 $180 
copayment for outpatient diagnostic test.  
You have been asked to pay a $180 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $100.13, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on February 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from January 3, 2023, 
to February 13, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you should not have to pay the 
copayment because a representative talked you out of your previous insurance plan and now you have 
copayments and large bills. 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 $0 
copayment for days 1 to 20 and a $196 copayment for days 21 to 100 for SNF care.  
 
 You have been asked to pay $4,116 for a SNF visit ($196 per day x 21 days = $4,116). 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 visit provided 
from January 3, 2023, to February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on December 18, 2022, to January 27, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the injection. You say that the enrollee's placement at the facility was due to 
behavioral issues and a group home refusing to accept the enrollee back. The Plan denied your request. The 
Plan says that the injection can be provided 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 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 an injection provided on December 18, 2022, to 
January 27, 2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from February 1, 
2023, to March 1, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you were unaware coverage had 
ended and an out-of-pocket expense began. 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- 20 and a $196 copayment per day for days 21-100 for SNF care.  
 
 
  You have been asked to pay $1,960 for a SNF visit ($196 per day x 10 days = $1,960). 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 visit provided 
from February 1, 2023, to March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve the dental services. You say that your crown is cracked and needs to be 
replaced. 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 March 2, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2751).
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 records provided support medical necessity. 
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 the enrollee has signal abnormality within 
the T7 vertebral body on MRI of the thoracic spine on April 7, 2023. The notes show the request should be of 
radionuclide bone scan and not a PET/CT. The bone scan will be sufficient to evaluate the nature of the signal 
abnormality of T7 and should be approved if requested. 
 
 
  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional routine transportation trips (A0110). 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you need the additional trips 
for visits once a month to your physician for prescriptions of your medications.  The Plan denied your request. 
The Plan says your benefit plan does not cover more than 10 one-way trips per plan year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 14 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 14 additional routine transportation trips (A0110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam (D3910). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure is necessary to retreat your 
root canal. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical procedure for isolation of tooth with rubber dam (D3910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization procedures (37225, 37226, 37227, 
37228, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve revascularization procedures. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 revascularization procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization procedures (37225, 37226, 37227, 37228, 37229, 37230, 
37231).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP) is covered when specific criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic deformity, 
or a severe impact on her daily activities. Moreover, there is MRI corroboration of retropulsion. There are 
plausible other causes of the pain. Therefore, the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and placement of intra-
socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) provided on February 20, 
2023. 
 
You asked the Plan to pay for the extraction and placement of intra-socket biological dressing. You say that 
you thought you had complete dental coverage. The Plan denied your request. The Plan says the is no coverage 
for the extraction and placement of intra-socket biological dressing 
 
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 an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210), and placement of intra-socket biological dressing to aid in hemostasis 
or clot stabilization, per site (D7922) provided on February 20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 11042, 11044, 11045, 11047, 99309 
rendered on June 2, 2022. 
 You asked the Plan to pay for the procedure codes 11042, 11044, 11045, 11047, 99309. 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 11042, 11044, 11045, 11047, 99309 
rendered on June 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) report provided on March 2, 
2023. 
 You asked the Plan to pay for the EKG report. 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 an electrocardiogram (EKG) report provided on March 2, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 18, 2022, to 
August 11, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 18, 2022. The NOA was not received by the Plan until February 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from July 18, 2022, to August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 14, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you appealed 
a previous CT scan that you won and this CT scan was a follow-up to the previous one. 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 $195 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $195 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $89.81, which is less than the standard copayment for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471 x 2), removal of 
torus mandibularis (D7473 x 2), therapeutic parenteral drugs (D9612) and intravenous moderate sedation 
(D9243). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary to proceed 
with your treatment. The Plan denied your request. The Plan says these services are not covered under the 
Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of lateral exostosis (D7471 x 2), removal of torus mandibularis (D7473 x 2), therapeutic parenteral 
drugs (D9612) and intravenous moderate sedation (D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM system. 
 
You asked the Plan to pre-approve therapeutic CGM system. You say that you do not agree with the denial for 
the CGM system. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a 
therapeutic CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin and you do 
not have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of therapeutic CGM system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve therapeutic CGM system.