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

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on May 2, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 3, 2022. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on May 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on October 19, 2022. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support the services. 
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 skilled nursing facility 
provided on October 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this specific drug is not FDA-approved for 
this enrollee's condition. Also, the major drug compendia and CMS-approved journals do not current show 
supportive high-quality evidence to support its use in this clinical situation at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 29, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this facility is not a hospital and is not affiliated with a 
hospital. They are actually unable to obtain Medicare approval/certification. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on March 29, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit provided on September 19, 
2022. 
 You asked the Plan to pay for the ER visit. You say that the services were provided prior to the hospice 
enrollment. 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 emergency room (ER) visit provided on September 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted with the Plan's authorization. 
 
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 retainer crowns exhausted on June 15, 2023, when the plan authorized coverage for a 
pontic for teeth (#3, #4, #5) and retainer crown for tooth (#2). Therefore, we decided that the Plan does not 
have to pre-approve retainer crowns (D6740).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an MRI provided on March 14, 2023. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are getting billed twice for the same 
service. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for each Medicare-covered MRI at a freestanding provider performed on 
the same day, by the same provider.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $75 
copayment for each MRI that is performed on the same day, by the same provider. The Plan contract does not 
clearly say how much enrollees must pay for more than one MRI performed during a single visit, by the same 
provider. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
Therefore, we decided that the Plan has to waive the copayment for an MRI provided on March 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for PT visits and surgery services provided 
from February 2, 2023, to February 27, 2023. 
 
You asked the Plan to reduce the copayment for PT visits and surgery services. You say that you paid $400 
already but received a bill for $1,870 that you feel the Plan should have adjusted. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for surgery services provided at an outpatient hospital and a $40 copayment for each physical 
therapy visit.  
 You have been asked to pay a $1,870 copayment for PT visits and surgery services. This total includes a $400 
copayment for the PT visits ($40 per visit x 10 visits = $400) and $1,470, which is less than the standard $250 
copayment per visit, for surgical services ($210 per visit x 7 visits = $1,470). The surgery services fall within 
the outpatient hospital services benefit category. The PT visits fall 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 reduce the copayment for PT visits and surgery services 
provided from February 2, 2023, to February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service February 25, 
2023. 
 
You asked the Plan to pay for procedure code S9083. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants for teeth #22 and 27 (D6010 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 
endosteal implants for teeth #22 and 27 (D6010 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this decision so you can get the 
proper care to get the right rehabilitation for you to go home. You also say your status requires minimal 
assistance and your therapist is recommending IRF services instead of services in a skilled nursing facility.  
The Plan denied your request. The Plan says the requested IRF admission is not medically necessary.  
 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has tried conservative management 
without improvement of symptoms. The Plan denied your request. The Plan says that 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 medically necessary. Our physician reviewer found the enrollee has tried conservative therapy 
including steroid injections on both sides. The physical exam shows positive signs of rotator cuff pathology, 
and the x-rays show evidence of chronic rotator cuff tears with high riding humeral heads. Due to all these 
factors the requested MRI both shoulders are medically 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of an upper extremity joint.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), the intraoral 
comprehensive series of radiographic images (D0210), and a cleaning (D1110) provided by an out-of-network 
provider on January 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the x-rays should have been covered by 
the Plan. 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. 
 
  The total amount billed for the comprehensive oral evaluation was $106 and the total allowed amount was $41 
leaving a difference of $65 ($106 billed - $41 allowed). The total amount billed for the intraoral comprehensive 
series of radiographic images was $202 and the total allowed amount was $80 leaving a difference of $122 
($202 billed - $80 allowed). The total amount billed for the cleaning was $107 and the total allowed amount 
was $52 leaving a difference of $55 ($107 billed - $52 allowed). The total difference amount for the dental 
service was $242 ($65 difference + $122 difference + $55 difference). 
 
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 a comprehensive oral evaluation (D0150), 
the intraoral comprehensive series of radiographic images (D0210), and a cleaning (D1110) provided by an 
out-of-network provider on January 3, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes A5500 and A5512 rendered on April 17, 
2023. 
 You asked the Plan to pay for the procedure codes A5500 and A5512. 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 A5500 and A5512 rendered on April 17, 
2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services provided on March 27, 
2023. 
 You asked the Plan to pay for subsequent hospital care services. You say that the charges denied in error 
stating patient was enrolled in hospice during the date of services billed for this claim. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care services provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on April 6, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation - new or established patient. You say that that 
after you had radiation in your throat you have had a lot of teeth problems. You also say that you have had 
infections and it now requires an extraction. The Plan denied your request. The Plan says your benefit for the 
comprehensive oral evaluation - new or established patient  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 comprehensive oral evaluation - new or established patient  was exhausted on date 
of service May19, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation - new or established patient (D0150) provided on April 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catherization (93458). 
 
You asked the Plan to pre-approve cardiac catherization. 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 cardiac catherization. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support a need for repeat diagnostic cardiac catheterization in this 
setting. As a result, at this time repeat diagnostic cardiac catheterization would not be considered medically 
appropriate and necessary in this enrollee's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catherization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catherization (93458).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the enrollee exhibits severe oxygen dependent 
chronic obstructive pulmonary disease (COPD) with hypercapnic respiratory failure and average volume 
assured pressure support (AVAPS) ventilatory support would improve quality of life (QOL) and 
symptomatology the enrollee was experiencing. There is a possibility of reduced hospitalizations, although 
uncertain. Ultimately, without transplantation, the enrollee carries and very poor prognosis and Non-invasive 
ventilation (NIV) would be only modality to improve QOL. 
 
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 ventilator have been met. Therefore, we decided that the Plan has to pre-
approve a ventilator (E0466).  
 
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.