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

We decided that the Plan does not have to waive the cost share forthe diagnostic radiology services and Part B prescription drug services provided on May 20, 2020.You asked the Plan to waive the cost share forthe diagnostic radiology services andPart B prescription drug services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received diagnostic radiology services and contrast material on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.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 $110 copayment for each Medicare-covered radiological diagnostic service performed at a free-standing facility and a 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received 3 separate CT scans and contrast material on May 20, 2020. You have been asked to pay a $110 copayment for each CT scan, totaling $330. The CT scans fall within the Outpatient diagnostic tests benefit category. You have been asked to pay a $1.80 coinsurance for the contrast material received on May 20, 2020. The contrast material falls within the Medicare Part B prescription drug benefit category. This means that you have been asked to pay the correct amounts 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 thatthe Plan does not have to waive the cost share forthe diagnostic radiology services and Part B prescription drug services provided on May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 31, 2020, to August 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
copayment amount. 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 $300 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per day for days 1-4 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,200 ($300 x 4 days = $1,200). An 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 an inpatient 
hospital stay provided by a participating provider on July 31, 2020, to August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee on June 30, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 outpatient services provided to the enrollee on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on April 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the remaining copayment for physical therapy provided from 
March 3, 2020, through May 11, 2020. 
 
You asked the Plan to waive the remaining copayment for physical therapy. You say that you paid your 
copayment each time. You say that you want to know why you owe more. The Plan denied your request. The 
Plan says the copayments were 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 $25 
copayment for each Medicare-covered physical therapy and speech-language therapy visit. 
 
You have been asked to pay a $25 copayment for each physical therapy visit. Physical therapy falls within the 
"Outpatient Rehabilitation Services" benefit category. The Plan says that you paid all but one $25 copayment 
for physical therapy provided in May. 
 
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 remaining copayment for physical therapy provided from March 3, 2020, 
through May 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the additional Skilled Nursing Facility (SNF) services.. You say that the 
services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 the additional Skilled Nursing Facility 
(SNF) services.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 
as a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of 
care after the last covered date. Ongoing care is custodial in nature. 

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 additional Skilled Nursing Facility (SNF) services. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional Skilled Nursing Facility (SNF) 
services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory virus testing provided on May 12, 2020. 
 
You asked the Plan to pay for the lab services. You say that the panel provides a complete picture of the 
enrollee's respiratory health. The Plan denied your request. The Plan says use is restricted to when more limited 
panels would not be medically appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87633 is not supported in the medical record. Specifically, there are insufficient 
medical records provided to show that the results of the testing will be used to determine a specific treatment 
strategy. This testing is not covered for screening purposes.  Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for respiratory virus testing provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on October 15, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 has network providers 
available who can provide 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 office visit (99214) provided on October 15, 
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 10, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 8017. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says that while a portion of this claim was paid, the physician order 
provided for this testing was incomplete and does not support medical necessity. The specimen collected for 
testing (blood versus urine) also was not appropriately documented for the codes used.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the records provided do not support the 
services billed.  Therefore, we decided that the Plan does not have to pay for lab services provided to the 
enrollee on March 10, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159, and 8017.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to 
the enrollee from April 7, 2020, to June 23, 2020. 
 
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 this is an invalid procedure code for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. 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 home infusion therapy services 
(HCPCS S9328) provided to the enrollee from April 7, 2020, to June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on June 
1, 2020. 
 
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 the documentation indicates the services are not necessary for treatment of the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
provided to the enrollee on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the obturator prosthesis (D5936) provided on June 11, 2020. 
 
You asked the Plan to pay for the obturator prosthesis (D5936). You say that this service was covered under 
your previous insurance. You also say that you were told your current insurance was better. The Plan denied 
your request. The Plan says the dental allowance plan does not provide benefits for this service. The Plan also 
says that this service is medical in nature. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
obturator prosthesis (D5936) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
bitewings (D0274) provided on December 17, 2019, and February 24, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and bitewings. You say that this is a 
hardship because you were not told that you would have to pay anything out of pocket. The Plan denied your 
request. The Plan says these services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
problem focused limited oral evaluation (D0140) and bitewings (D0274) provided on December 17, 2019, and 
February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 23, 2019 to May 
26, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that your facility took great care in treating 
this enrollee with the expectation that there services would be reimbursed accordingly. The Plan denied your 
request. The Plan says that based on the clinical records, observation level of care will be covered my the Plan. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found This enrollee presented with significantly high blood sugar in the setting of hypertensive 
emergency and acid base disorder. This makes it reasonable to expect this enrollee would require hospital care 
to span 2 midnights in order to normalize his blood sugar as well as his kidney function in the setting of a 
newly diagnosed diabetic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 23, 2019 to May 26, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 3, 2020. 
 
You asked the Plan to waive the copayment for wound care. You say that you have had these services before 
and have never had to pay this much. 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 $225 
copayment for outpatient surgery/hospital facility.  
 
You have been asked to pay a $225 copayment for wound care. The services that were provided are considered 
an outpatient surgery; therefore, the correct copayment has been applied. Wound care falls within the outpatient 
surgery/hospital facility 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 
outpatient surgery provided by a participating provider on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical application of fluoride excluding varnish 
(D1208), core buildup, including any pins when required (D2950), and prefabricated post and core in addition 
to crown (D2954). 
 
You asked the Plan to pre-approve the topical application of fluoride, core buildup, and prefabricated post and 
core. You say that the enrollee is experiencing discomfort, needs this treatment, and would benefit from the 
services. The Plan denied your request. The Plan says these services are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
topical application of fluoride excluding varnish (D1208), core buildup, including any pins when required 
(D2950), and prefabricated post and core in addition to crown (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. The Plan denied your request. The Plan says 
you had a cleaning within the past 12 months. The Plan also says that you cannot get this type of deep cleaning 
of your whole mouth within 12 months of a regular cleaning or oral or periodontal evaluation. 
 
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 requested items or services are not 
among those covered under this benefit. The record shows that you received a comprehensive oral evaluation 
on August 21, 2020. The contract states that a full mouth debridement (D4355) may be provided to enable a 
comprehensive oral evaluation and diagnosis on a subsequent visit.  
 
 
 
 
 
 
 
 
 
 
 
The full mouth debridement would need to be performed prior to a comprehensive oral evaluation. Therefore, 
we decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower 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.