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

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 
2023, to March 3, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the cost share 
applied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20, a $196 copayment for days 21 to 52, and $0 copayment for days 53 to 
100 for SNF care.  
 
 The enrollee has been asked to pay $3,528 for a SNF stay ($196 per day x 18 days = $3,528). This item/service 
falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
SNF stay provided from February 1, 2023, to March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3020).  
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered as you disagree with the 
denial. 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 pay for foot orthotics 
(L3020).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interspinous device and L5-S1 
decompression procedure. 
 
You asked the Plan to pre-approve the Coflex interspinous device and L5-S1 decompression procedure. You 
say that the service is medically necessary. You say the enrollee's quality of life will be severely reduced if they 
do not get this surgery.  The Plan denied your request. The Plan says the Coflex interspinous device and L5-S1 
decompression is not medically necessary.  
 
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 the Coflex interspinous device and L5-
S1 decompression procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental, and more research is needed. This means that the requested services are not 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 Coflex interspinous device and L5-S1 decompression procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex interspinous device and 
L5-S1 decompression procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that the enrollee came in on 
multiple occasions and let you know that a family member stole her partial. You also say that per the Plan you 
were asked to file an appeal and include the police report the enrollee was to give you but it was never 
provided. The Plan denied your request. The Plan says your benefit for the mandibular partial denture 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 service was exhausted on date of service May 24, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226).
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 you do not agree with the denial of the 
requested items. The Plan denied your request. The Plan says these items are 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they must follow Medicare rules. The plan will 
cover services with an out-of-network provider when none of the in-network providers can provide the service 
that is being 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on the 
lower left and lower right quadrant and a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that for you to provide appropriate care for the 
enrollee the requested dental services are necessary. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 the Plan paid for the periodontal scaling and root planing (D4341) on the lower left and lower right 
quadrant and a partial lower denture (D5214) on May 9, 2022; therefore, the enrollees benefit for the requested 
the partial lower denture (D5214) was exhausted on the date of service of May 9, 2022. Therefore, we decided 
that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on the lower left 
and lower right quadrant and a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like to have a second opinion. The 
Plan denied your request. The Plan says you must receive care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator . You say that the lower part of the left lung partially 
collapsed because you were not able to breath in deep enough. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found that you do not have 
documented or supportive needs for a home ventilator. Although you have COPD there is no data to support a 
BiPAP failure or requirements for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you suffer from 
cancer, do not have close relatives who can assist you, and do not have a vehicle. The Plan denied your request. 
The Plan says more than 32 one-way trips are non-covered by the Plan. 
 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 32 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 additional non-emergency transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the requested ventilation system will 
help the enrollee remain mobile in their home and carry out more activities of daily living.  The Plan denied 
your request. The Plan says a home ventilator is not medically necessary for this patient because their needs 
can be met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that although the 
enrollee has severe disease with sarcoidosis and chronic respiratory failure, the documentation does not support 
the needs for a home ventilator. Further data and documentation are required to confirm the need of a 
ventilator. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve the reverse total shoulder arthroplasty. You say that the enrollee has 
weakness and cannot lift his arm. You say the enrollee has tried oral medications, physician-directed exercises, 
and an x-ray that shows chronic rotator cuff tearing.  The Plan denied your request. The Plan says the reverse 
total shoulder arthroplasty is not medically necessary.  
 
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 the reverse total shoulder arthroplasty. 
Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee was being treated for rotator cuff arthroplasty of the right shoulder 
and bicipital tendinitis of the right shoulder. The documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. There is no documentation 
of physical therapy having been trialed. Additionally, the provided diagnostic imaging studies did not 
corroborate a massive rotator cuff tear that is irreparable. There is no compelling rationale or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
reverse total shoulder arthroplasty is not medically reasonable or 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 reverse total shoulder arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the reverse total shoulder arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee lost their previous dentures 
and it is medically necessary to replace them. The Plan denied your request. The Plan says your benefit for the 
requested items or services 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 the Plan paid for a complete upper denture (D5110) and a partial lower denture (D5212) on June 23, 
2022; therefore, the enrollees benefit for the requested items or services was exhausted on the date of service 
of June 23, 2022. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a partial lower denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pain management visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a pain management visit. You say that you do not agree with the denial to 
see the out-of-network provider. The Plan denied your request. The Plan says the service can be provided by an 
in-network provider. 
  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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pain management visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), an 
abutment supported to denture (D6111), and the prefabricated abutment (D6056) for tooth #22 and #27. 
 
You asked the Plan to pre-approve the dental services. You say that you would like your temporary dentures to 
be covered while you wait for the permanent dentures. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because the surgical placement of implant body, the abutment 
supported to denture, and the prefabricated abutment are not covered by the 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 the 
surgical placement of implant body (D6010), an abutment supported to denture (D6111), and the prefabricated 
abutment (D6056) for tooth #22 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve over-the-counter (OTC) services to be carried over. 
 
You asked the Plan to pre-approve OTC services to be carried over. You say that you should be eligible for the 
first two quarters since you were not aware that you were eligible for the OTC program. The Plan denied your 
request. The Plan says OTC benefits do not carry over from previous quarters. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. 
  We looked at the file and the Plan rules. The Plan rules say that quarterly allowances cannot be carried over to 
another quarter. Based on this information, we decided that Medicare rules for coverage of OTC services to be 
carried over have not been met. Therefore, we decided that the Plan does not have to pre-approve over-the-
counter (OTC) services to be carried over.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on April 28, 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 April 28, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic 
image (D0230) provided on April 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
April 26, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you were supposed 
to have an infusion done that day and were then sent to the ER and then hospitalized for no reason. 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 $300 
copayment per day for day(s) 1-5 for inpatient hospital services.  
 
You have been asked to pay a $300 copayment per day for an in-network inpatient stay. This item/service falls 
within the inpatient hospital 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 an in-network inpatient stay provided from April 26, 2023, 
to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that there is a billing processing issue with our system 
and must be resolved. The Plan denied your request. The Plan says the services are not authorized because 
Puget Sound Chiropractic LLC is a non-network provider who does not work with the enrollee's health Plan. 
 
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 office visit provided on February 15, 2023, by 
an out-of-network (OON) provider.