Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 09, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on January 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from March 6, 2023, to March 9, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this math 
doesn't add up, how can I still owe $670? This is too much. 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 $335 
copayment each day for days 1 to 5 for Medicare-covered hospital care for inpatient hospital care.  
 
You were in the hospital for 2 days, resulting in a $670 total copayment ($335 x 2 = $670). You have been asked to pay a $670 copayment each day for days 1 to 5 for Medicare-covered hospital care for 
an in-network acute inpatient stay. This item/service falls within the inpatient hospital care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an in-network acute inpatient stay provided from March 6, 
2023, to March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 28, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services rendered were 
medically necessary. 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 subsequent nursing 
facility care provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 additional units of procedure code 88341 rendered on 
January 16, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no specific rationale for performing excess units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that 26 units of 
immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure 
was performed and are being requested, of which 13 units were approved. However, the remaining units (13) 
were not sufficiently supported in the provided documentation. There was no explanation found as to why these 
additional units were needed over the approved 13 units. The documentation does show these extra units were 
provided; however, they will be considered not medically necessary.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for 13 additional units of procedure code 88341 rendered on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an intravitreal injection of a 
pharmacologic agent (67028) and an aflibercept injection (J0178), or the copayment for a medical eye 
examination (92014) and fundus photography (92250) provided from February 6, 2023, to February 15, 2023.  
 
You asked the Plan to waive the coinsurance for an intravitreal injection of a pharmacologic agent (67028) and 
an aflibercept injection (J0178), and the copayment for a medical eye examination (92014) and fundus 
photography (92250). You say that you did not receive any eye injections on February 6, 2023. You also say 
that you did not see the doctor on February 15, 2023. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs, including chemotherapy drugs. The Plan contract also says that there is 
a $35 copayment for each Medicare-covered eye examination. 
 
You have been asked to pay $361.20 coinsurance, which is 20% of the allowed amount for an intravitreal 
injection of a pharmacologic agent (67028) and an aflibercept injection (J0178) ($1805.98 x 20% = $361.20). 
This item/service falls within the Medicare Part B drugs, including chemotherapy drugs benefit category. You 
have also been asked to pay a $35 copayment for a medical eye examination (92014) and fundus photography 
(92250). This item/service falls within the Medicare-covered eye examination 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 record shows that you received the 
injection on February 6, 2023. The record also shows you had a medical eye examination with diagnosis on 
February 15, 2023. Therefore, we decided that the Plan does not have to waive the coinsurance for an 
intravitreal injection of a pharmacologic agent (67028) and an aflibercept injection (J0178), or the copayment 
for a medical eye examination (92014) and fundus photography (92250) provided from February 6, 2023, to 
February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on February 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental appliance was recommended to stop 
sleep apnea. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the occlusal guard is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard (D9944) provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5211). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service June 24, 2022. Specifically, the 
Plans contract states that partial dentures are covered once every five years. You previously received an upper 
partial denture on June 24, 2022, less than five years prior, which was paid for by the Plan.   
 
 
 
 
Therefore, you have exhausted the allowable benefit for the dental item requested in this case. Therefore, we 
decided that the Plan does not have to pre-approve an upper partial denture (D5211).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 06, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration. 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 the laboratory services 
provided on January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0366), an endosteal implant 
(D6010), a semi-precision abutment (D6191), replacement of a semi-precision abutment (D6091), and an 
implant supported removable denture (D6112). 
 
You asked the Plan to pre-approve D0366, D6010, D6191, D6091, and D6112. You say that you need this 
dental work. The Plan denied your request. The Plan says the requested dental services are not covered 
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 a cone beam CT capture (D0366), an endosteal implant (D6010), a semi-precision abutment (D6191), 
replacement of a semi-precision abutment (D6091), and an implant supported removable denture (D6112).
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 romosozumab monthly injection for one year 
followed by bisphosphonate is the optimal management for the enrollee. The Plan denied your request. The 
Plan says that the step therapy requirements have not been met. 
 
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 Evenity 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonates. Also, there is no indication that the Plan's required drug would likely be less 
effective 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration as 
the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says criteria for 
admission to the acute IRF setting have not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine. 
 
You asked the Plan to pre-approve the MRI. You say that the x-ray results showed diffuse osteopenia, 
degenerative disc disease, and thoracic levoscoliosis. 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 osteopenia and is thus at risk for 
compression fracture despite plain x-rays showing none. She has tried PT and has persistent pain. Criteria for 
thoracic spine MRI have been met. 
 
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 the thoracic spine.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes E0184, E0630, E0260, E091 provided 
on April 28, 2023. 
 You asked the Plan to pay for the procedure codes E0184, E0630, E0260, E091. You say that the enrollee was 
not enrolled in hospice on the date of service. 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 April 27, 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 the procedure codes 
E0184, E0630, E0260, E091 provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation for moderate sedation, deep sedation, or 
general anesthesia (D9219). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under the supplemental 
dental policy.  
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
evaluation for moderate sedation, deep sedation, or general anesthesia (D9219).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified periodontal procedures, by report  
(D4999 x 4) and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy. 
 
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 services are not among 
those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pre-approve unspecified periodontal procedures, by report 
(D4999 x 4) and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a complete 
series of radiographic images (D0210), and the extractions (D7140 and D7210) for tooth #8, #20, #21, #22, 
#23, #24, #26, #27, and #28 provided by an out-of-network provider on February 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were in extreme pain from the process 
that the dentist used for the extractions and the x-rays were necessary after the extractions were done. 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 billed amount for the comprehensive oral evaluation (D0150) was $94 and the total allowed amount 
was $38 leaving a difference of $56 ($94 billed - $38 allowed). The total billed amount for the complete series 
of radiographic images (D0210) was $189 and the total allowed amount was $79 leaving a difference of $110 
($189 billed - $79 allowed). The total billed amount for each of the extractions (D7140) for tooth #23 and #26 
was $187 and the total allowed amount was $62 leaving a difference of $125 ($187 billed - $62 allowed). The 
total billed amount for the extraction (D7210) for tooth #27 was $303 and the total allowed amount was $116 
leaving a difference of $187 ($303 billed - $116 allowed). The total billed amount for each of the extractions 
(D7140) for tooth #8, #20, #21, #22, #24, and #28 was $303 and the total allowed amount was $62 leaving a 
difference of $241 ($303 billed - $62 allowed). 
 
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), a 
complete series of radiographic images (D0210), and the extractions (D7140 and D7210) for tooth #8, #20, 
#21, #22, #23, #24, #26, #27, and #28 provided by an out-of-network provider on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
March 31, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or 
re-bond of a crown (D2920) provided on March 31, 2023.