Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. The Plan will continue to cover medically necessary acute 
and critical care at the current facility until the enrollee's condition is stable to transfer to an alternate level of 
care (such as a skilled nursing facility), or until the circumstances change such that LTACH may be 
reconsidered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (99203). 
 
You asked the Plan to pre-approve a consultation . You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 a consultation =. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. There are no corroborated acute pathologies of the knee identified 
and the need for specialized care of the knee is not clearly documented. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception.   
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 consultation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a consultation (99203).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine 
(72131). 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary as the physician notes do not say why 
magnetic resonance imaging (MRI) cannot be done. 
 
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 a CT scan of the lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found during the encounter of 
November 17, 2022, there is a note stating an MRI was ordered per direction of the pain specialist. The 
enrollee has had a prior MRI on October 29, 2016, and there is no contraindication in the submitted records to a 
repeat MRI lumbar spine. 
 
   
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 CT scan of the lumbar spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine (72131).
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. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery, bone replacement graft, and extraction 
(D4260, D4261, D7210, D7953) provided on July 15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for 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 dental extraction was received from an out-of-
network provider and are not covered by your supplemental benefits. Coverage for the osseous surgery and 
bone replacement graft 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for osseous surgery, bone replacement graft, and extraction (D4260, D4261, D7210, D7953) provided 
on July 15, 2022, by an out-of-network (OON) provider.
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 
November 30, 2022, to December 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that these services cost less 
than in the United States, and you should not have to pay the full copayment amount. 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 $325 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $325 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day five 
or for the day you were discharged. You have been asked to pay a total of $1,625 ($325 copayment per day x 5 
days = $1,625). 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 
November 30, 2022, to December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on February 22, 2023. 
 
You asked the Plan to pay for 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 pay for an 
intraoral x-ray (D0220) provided on February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on November 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Zoledronic acid or Prolia first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Zoledronic acid or Prolia first before they will approve the requested drug. In this case, the enrollee has not 
tried and failed a required drug. There is no documentation provided indicating that the plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on August 29, 
2022. 
 
You asked the Plan to pay for 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 pay for a 
maxillary partial denture (D5213) provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the primary care provider office visit 
provided on January 2, 2023. 
 
You asked the Plan to waive the deductible for the primary care provider office visit. You say that you do not 
understand these charges. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to out-of-network primary care 
provider office visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance after 
meeting the deductible for out-of-network primary care provider office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $300 deductible which applies to out-of-network primary care provider office visits. This cost sharing is a 
contractual obligation that had not been met at the time the primary care provider office visit was received on 
January 2, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the primary care 
provider office visit provided on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network dermatology visit provided 
on January 04, 2023. 
 
You asked the Plan to waive the deductible for an in-network dermatology visit. You say that you want to 
know exactly how much your deductible is because you keep getting different numbers. 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. Your 
contract with the Plan says that there is a $625 deductible, and a maximum out of pocket (MOOP) amount of 
$6,500 which applies to Physician/Practitioner services, including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $625 deductible, and a maximum out of pocket (MOOP) amount of 
$6,500 which applies to Physician/Practitioner services, including doctor's office visits.  
 This cost sharing is a contractual obligation that had not been met at the time an in-network dermatology visit 
was received on January 4, 2023. Therefore, we decided that the Plan does not have to waive the deductible for 
an in-network dermatology visit provided on January 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and diagnostic casts 
(D0330, D0470) provided on February 8, 2023. 
 
You asked the Plan to pay for 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 dental x-rays was exhausted 
on the appeal claim. Coverage for the diagnostic casts 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 8, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image and diagnostic 
casts (D0330, D0470) provided on February 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the oxygen concentrator provided by an in-
network provider on February 1, 2023. 
 
You asked the Plan to waive the deductible for the oxygen concentrator. You say that you cannot afford the 
deductible amount. 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. Your 
contract with the Plan says that there is a $200 deductible which applies to all services besides Part D pharmacy 
services, health and wellness education programs, worldwide coverage, and Covid-19 tests and treatment.  
 
 
 
 
 
 You have been asked to pay a $70.23 deductible for the oxygen concentrator. The item or service you asked the 
Plan to waive the deductible for falls within the durable medical equipment (DME) and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 
deductible which applies to durable medical equipment (DME) and related supplies. This cost sharing is a 
contractual obligation that had not been met at the time the oxygen concentrator was provided on February 1, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the oxygen concentrator 
provided by an in-network provider on February 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.   
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5130) purchased on 
February 10, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items are not payable as they 
were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5130) purchased on February 10, 2023.