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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 23, 2023, to February 26, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 1-6 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-6 for inpatient hospital care. You are being 
asked to pay $325 per day for days 1-6. The total amount you are being asked to pay is $1,300 ($325 x 4 days = 
$1,300). 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 inpatient hospital care provided on February 23, 2023, to February 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
7, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. The Plan denied your request. The Plan says 
your benefit for the panoramic radiographic image has already been exhausted. The Plan also says that 
procedure codes D0330 and D0210 (intraoral-comprehensive series of radiographic images) share frequencies. 
Only one of the two codes can be billed once every 36 months 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown-porcelain/ceramic on tooth# 18 (D2740) and crown-
porcelain fused to predominant base metal on tooth# 18 (D2751) provided on March 3, 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 $1,000 annual maximum 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. Therefore, we decided that the Plan does not have to pay for crown-porcelain/ceramic on tooth# 18 (D2740) and crown-porcelain fused to predominant 
base metal on tooth# 18 (D2751) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a BiPAP has been tried. The Plan denied your 
request. The Plan says the requested settings can be delivered by a BiPAP device.  
 
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 physician reviewer 
found that the enrollee has severe COPD and was recently hospitalized with an exacerbation.   Intubation and mechanical ventilation were required. The enrollee was eventually extubated and discharged to 
a skilled nursing facility. An arterial blood gas done after discharge, after using BiPAP during sleep, showed 
persistent mild compensated carbon dioxide retention. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. This enrollee may benefit from BiPAP with advanced volume-assured pressure support 
(AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. Therefore, the request is 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with a patient 
weight capacity up to and including 300 pounds (K0823) and a 22nf sealed lead acid battery (E2361). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and 22nf sealed lead acid battery. You 
say that the provided documentation shows that the enrollee's home is clearly power wheelchair accessible. The 
Plan denied your request. The Plan says the requested power chair will not accommodate the members weight 
as the member weighs more than 300 pounds. The Plan also says that it is clear that the enrollee's motor home 
will not allow the requested wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 standard power wheelchair and 22nf sealed lead acid battery have not been met. 
Specifically, the provided records show that the enrollee's most recent documented weight is above the required 
weight limit of up to and including 300 pounds for the requested group 2 standard power wheelchair (K0823). 
Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with a 
patient weight capacity up to and including 300 pounds (K0823) and a 22nf sealed lead acid battery (E2361).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has tried physical therapy and 
medications with no relief. The Plan denied your request. The Plan says that an epidural steroid injection is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the 
enrollee does meet the coverage criteria. Our physician reviewer found that the physician is going to change 
levels since the prior epidural steroid injection only lasted one month. Also, there is a specific clause in the 
LCD that allows for a change of approach if there is an unsatisfactory result. Therefore, the request is 
medically reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits x19. 
 
You asked the Plan to pre-approve home health services. You say that the requested physical therapy visits are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing; home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision).  As such, the requested, ongoing, home health physical therapy services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits x19.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aortic valve repair and an aortic root graft (AVAR). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has intermittent dizziness 
and chest pains. The Plan denied your request. The Plan says the enrollee does not have a left ventricular 
ejection fraction of less than 50 percent. 
 
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 requested services. Our physician 
reviewer found that the enrollee has shortness of breath and aortic stenosis. Imaging shows an aortic valve area 
of 0.86 square centimeters and an ejection fraction of 55-60 percent. Guidelines would not support AVAR 
based on the submitted medical records. As a result, at this time the requested AVAR would not be considered 
medically necessary in this enrollees clinical management based on the submitted documentation. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an aortic valve repair and an aortic root graft (AVAR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture - flexible base (D5226) 
provided on August 31, 2022. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you believe too much money was 
paid to the provider without disclosing it to you first. The Plan denied your request. The Plan says your benefit 
for the mandibular partial denture - flexible base $2,500 dollar limit was met. 
 
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 a mandibular partial denture - flexible base was exhausted on date of service July 29, 
2022. Therefore, we decided that the Plan does not have to pay for a mandibular partial denture - flexible base 
(D5226) provided on August 31, 2022.  
 
Your complaint about the cost of your treatments is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services should be covered. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan has 
communicated with the provider telling them the claim has to be submitted to primary insurance. As the 
secondary insurer, the Plan cannot be held responsible for the lab services until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on March 3, 2022.
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 reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare criteria for admission to an IRF.  
 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support this expedited 
appeal. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for suspected bacteremia after recent back surgery. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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. There is not a reasonable expectation that the enrollee 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 acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that there are no transportation resources in your 
area. The Plan denied your request. The Plan says your benefit only allows 48 trips for this service. 
 
 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 48 one-way trips per year.  
 
The file shows that 72 additional trips were requested. We looked at your request, the records in the case file, 
and the rules. Once 48 trips have been used, you will have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you had you provider attest to your chronic 
illness of osteoporosis. You also say that you would qualify for this benefit because you have diabetes and 
other illnesses. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and the bitewings (D0272) and to pay for the intraoral radiographic image 
(D0230) provided by an out-of-network provider on February 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the provider was an in-
network provider, and you stopped seeing your regular dentist. The Plan denied your request. The Plan says 
your benefit for the intraoral radiographic image has already been exhausted. You are also responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. It was also verified there were no phone calls to the Plan prior to the date of service to verify benefits 
or provider status. 
 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 an intraoral radiographic image (D0220) on February 1, 2023; therefore, your benefit 
for the intraoral radiographic image (D0230) was exhausted on the date of service of February 1, 2023. The 
total amount billed for the limited oral evaluation (D0140) was $105 and the total allowed was $34 leaving a 
difference of $71 ($105 billed - $34 allowed). The total amount billed for the intraoral radiographic image 
(D0220) was $40 and the total amount allowed was $13 leaving a difference of $27 ($40 billed - $13 allowed). 
The total amount billed for the bitewings (D0272) was $63 and the total allowed amount was $20 leaving a 
difference of $43 ($63 billed - $20 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 the 
limited oral evaluation (D0140), the intraoral radiographic image (D0220), and the bitewings (D0272) and to 
pay for the intraoral radiographic image (D0230) provided by an out-of-network provider on February 1, 2023.