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

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from July 31, 2020, to 
August 5, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the care provided was unauthorized post-stabilization 
care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the inpatient hospital care. Our reviewer 
says that the inpatient care provided was unauthorized post-stabilization care.  
 
 
Our physician reviewer found the post-stabilization care services at the OON facility after 6:50 PM on July 31, 
2020, were not medically necessary or reasonable. The enrollee was hemodynamically and neurologically 
stable and appropriate for ambulance transport with monitoring to a Plan facility. The review has determined 
that the treating physician document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from July 31, 2020, to August 5, 2020, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on 
September 2, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you had the services in the past and 
were charged for a diagnostic eye exam. The Plan denied your request. The Plan says the copayment was 
applied 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 $40 
copayment per visit for a specialist office visit.  
 
Review of the file shows that you received specialist services on September 2, 2020. Per the contract with the 
Plan, there is a $40 copayment per visit for a specialist office visit. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services 
was $34.41. Given that the allowed amount was less than the $40 copayment, you have been asked to pay 
$34.41 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered 
on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant (D6010), the bone graft at time of implant 
placement (D6104), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation 
(D9223 x 3), and the therapeutic parenteral drug (D9610) provided on September 11, 2020. 
 
You asked the Plan to pay for the implant, bone graft, anesthesia and medication. You say that the dentist 
advised they did everything correct. You say that you went and talked to them. The Plan denied your request. 
The Plan says the implant and bone graft are not listed as covered services. The Plan also says that anesthesia is 
only covered when provided with covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental implant and bone graft are 
not among those covered under this benefit. The record shows that the anesthesia and medication were 
provided for procedures necessary for dental implants. Dental implants and related services are not covered and 
therefore the anesthesia and medication are not covered either.  
 
 
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the implant (D6010), the bone graft at time of 
implant placement (D6104), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep 
sedation (D9223 x 3), and the therapeutic parenteral drug (D9610) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on September 30, 2020. 
 
You asked the Plan to pay for the dental service. You say that the enrollee's dentist wanted her to have a 
cleaning done 4 times per year to make sure her teeth were brushed well. The Plan denied your request. The 
Plan says two cleanings per calendar year are covered. The Plan says that the frequency limit for this service 
has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of two cleanings 
per calendar year has been exceeded. The record shows that the Plan paid for cleanings that you received on 
February 25, 2020, and June 30, 2020. Therefore, we decided that the Plan does not have to pay for the 
cleaning (D1110) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on October 13, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that because you only have 8 teeth in your mouth 
the panoramic x-ray is necessary more often than every 5 years. The Plan denied your request. The Plan says a 
panoramic x-ray is a full mouth x-ray. The Plan also says that the panoramic x-ray was not covered due to 
frequency limitations. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, full mouth x-rays are limited to once 
every 5 years. The record shows that you received a panoramic x-ray on September 26, 2017, and your full 
mouth x-ray benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
August 4, 2020, to August 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the copayment has applied correctly in this 
case. 
 
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 $310 
copayment per day, days 1-7 for inpatient hospital care.  
 
You have been asked to pay a total cost share of $1860 for the inpatient hospital care (6 days x $310 
copayment). The services provided fall 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 the inpatient hospital care provided from August 4, 2020, to August 
10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy provided by a participating 
provider on September 18, 2020. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you do not think you should be 
charged for this. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $350 
copayment for outpatient surgery/ambulatory surgical center.  
 
You have been asked to pay a $350 copayment for an endoscopy. An endoscopy falls within the outpatient 
surgery/ambulatory surgical center 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 endoscopy provided by a participating provider on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99358) provided on October 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
does not support code 99358. 
 
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 99358 is "Prolonged evaluation and management service 
before and/or after direct patient care; first hour". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 99358 is not supported by the records provided. Our coding reviewer found that the 
documentation does not support that the prolonged service was not additional unit/floor time in the hospital or 
nursing facility setting during the same session of an evaluation and management service per AMA CPT 
guidelines.  Therefore this service cannot be verified. 
 
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 the services (CPT 99358) provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics and retainer crowns provided on July 16, 2020. 
 
You asked the Plan to pay for the pontics and retainer crowns. You say that you would like one of the retainers 
to be downgraded to a single crown, and paid for as an alternate benefit. The Plan denied your request. The 
Plan says there is no coverage for bridges. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pontics and retainer crowns are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
pontics and retainer crowns provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 30, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were told this was covered and previously had a 
referral. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 the medical services provided on January 30, 2020 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for rhabdomyolysis, viral pneumonia and NSTEMI after prolonged immobilization at home after 
a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam rendered on November 26, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your 
request. The Plan says the services exceeded the benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a routine eye exam once every two years. 
 
We looked at the file and the Plan's rules. The file shows that you previously had a routine eye exam on 
November 20, 2018 that the Plan covered. The routine eye exam on November 26, 2019 was performed less 
than two years from your previously covered exam. Based on this information, we decided that the Plan's rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the routine eye exam rendered on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating 
provider on October 6, 2020. 
 
You asked the Plan to waive the copayment for an injection. You say that you already paid a $15 copayment 
for the office visit. You say that you do not think you should have to pay for anything else. The Plan denied 
your request. The Plan says the correct copayment has been applied. 
 
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 $15 
copayment for Medicare Part B prescription drugs.  
 
You have been asked to pay $5.37 which is less than your copayment amount of $15 copayment for an 
injection administered professionally. An injection falls within the Medicare Part B prescription drugs 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 injection provided by a participating 
provider on October 6, 2020.
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 
August 11, 2020 to August 17, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you have had no 
income for the last 8 months because you went out of business due to Covid-19. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $350 
copayment per day, days 1-5 for each in-network Medicare-covered hospital admission/stay.  
 
You have been asked to pay a $350 copayment for each day of the inpatient hospital stay. ($350 x 5 days = 
$1,750). The inpatient hospital stay 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 the inpatient hospital stay provided from August 11, 2020 to August 
17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from April 1, 2020 to April 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for the services rendered from April 1, 2020 to April 
3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (CPT Code E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that you are having surgery and will need this 
item to get around. The Plan denied your request. The Plan says there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish medical necessity for crutch 
substitutes. 
 
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 crutch substitute. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the E0118 crutch substitute is not medically necessary. The documentation does not 
reveal that the device is safe and effective for your condition or that you are unable to use crutches after 
surgery if needed. 
 
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 crutch substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the crutch substitute (CPT Code E0118).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found you have stabilized medically and have been receiving skilled rehab services in an inpatient 
rehabilitation facility (IRF). You continue to require skilled nursing and/or skilled therapy services on an 
intermittent basis but otherwise has met your acute rehab goals. Although you were making slow progress with 
therapy, there is no indication that transfer to a skilled nursing facility was required. You could have continued 
to received skilled rehab services at the current IRF or been stepped down to a custodial care facility if needed. 
There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF 
for inpatient skilled rehab services was 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 SNF care have 
not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.