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

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from June 2, 2020 to 
July 8, 2020. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you knew your insurance only 
covered 20 days of rehabilitation. You say you were told not to worry because you were covered. 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 $0 
copayment per day, days 1-20 and a $178 copayment per day, days 21-100 for each SNF stay.  
 
You have been asked to pay a total of $2,136 for the SNF stay. The SNF stay falls within Skilled nursing 
facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan.  
  
 
Dates of 
Service 
Service Copayment 
per Day 
SNF Days Number of 
Days 
Member 
Liability 
June 13, 2020 to 
June 30, 2020 
SNF $0 1-18 18 $0 
June 2, 2020 to 
June 3, 2020 
SNF $0 19-20 2 $0 
June 4, 2020 to 
June 9, 2020 
SNF $178 21-26 5 $890 
July 1, 2020 to 
July 8, 2020 
SNF $178 27-33 7 $1,246 
Total     $2,136 
 
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 SNF stay provided from June 2, 2020 to 
July 8, 2020. 
 
Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information 
regarding the amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and outpatient 
rehabilitation services provided on August 19, 2020. 
 
You asked the Plan to waive the copayments for a specialist visit and outpatient rehabilitation services. You 
say that you disagree with the charges because you should only owe a $20 copayment. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 
copayment for specialist visits and outpatient rehabilitation services. 
 
You received specialist services on August 19, 2020. Therefore, you are responsible to pay the $20 copayment.  
 
You also received outpatient rehabilitation services on August 19, 2020. Therefore, you are responsible to pay 
the $20 copayment.  
 
The total amount you owe is: $40.   
 
You have been asked to pay the total copayment amount of $40 for a specialist visit and outpatient 
rehabilitation services. A specialist visit falls within the physician/practitioner services, including doctor?s 
office visits benefit category. Outpatient rehabilitation services fall within the outpatient rehabilitation services 
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 copayments for a specialist visit and outpatient 
rehabilitation services provided on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that the enrollee needs this drug two times per day. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 
Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of erupted tooth (D7210) and bone 
replacement graft (D7953) provided on July 9, 2020. 
 
You asked the Plan to pay for the extraction of erupted tooth and bone replacement graft. You say that these 
services were medically necessary. The Plan denied your request. The Plan says these services are not covered 
under your supplemental benefit 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 
extraction of erupted tooth (D7210) and bone replacement graft (D7953) provided on July 9, 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 
January 15, 2020, to January 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that this was an emergency 
situation and you would like the coinsurance waived. The Plan denied your request. The Plan says the 
coinsurance has processed correctly for 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 $290 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $290 copayment for the inpatient hospital care you initially received before 
being transferred on January 16, 2020. The inpatient hospital care 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 care provided from 
January 15, 2020, to January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the full mouth debridement provided on July 17, 2019. 
 
You asked the Plan to pay for the full mouth debridement. The Plan denied your request. You say that you have 
no history of having a deep cleaning, and have an approved pre-authorization for the service. The Plan says that 
a full mouth debridement cannot be billed within twelve months of a comprehensive oral evaluation. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the full mouth debridement by a contract provider. The provider is a contract provider. 
The file does not show that the Plan provided notice that the full mouth debridement would not be covered. The 
contract clearly states that you are limited to one full mouth debridement every three years. There is no 
evidence that this procedure had been provided before this service was rendered in that timeframe. Under 
Medicare rules, this means the full mouth debridement is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the full mouth debridement provided on July 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the lower 
extremity rendered on July 13, 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 procedure code 73720 was billed incorrectly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 73720 was not billed with the 
required anatomical modifier. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) of the lower extremity rendered on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) of 
the lumbar spine (72148) and magnetic resonance imaging (MRI) of the spinal canal provided on February 29, 
2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $100 
copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).    
 
You have been asked to pay $200 ($100 copayment x 2) for the in-network Medicare-covered radiological 
diagnostic services provided. 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 adjust the copayment for the magnetic resonance 
imaging (MRI) of the lumbar spine (72148) and magnetic resonance imaging (MRI) of the spinal canal 
provided on February 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe to be discharged to home. The 
Plan denied your request. The Plan says no documentation is provided to show that the complexity of the 
enrollee's nursing, medical management, and rehab needs require an inpatient stay. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for radical hysterectomy for stage III C ovarian cancer. 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 patient 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral mastopexy, augmentation mammoplasty 
bilateral and bilateral implant insertion. 
 
You asked the Plan to pre-approve bilateral mastopexy, augmentation mammoplasty bilateral and bilateral 
implant insertion.. You say that please reconsider the decision to allow coverage for the procedure. Her vision 
affects her ability to drive and this procedure is medically necessary in order to improve her activities of daily 
living. The Plan denied your request. The Plan says the requested services/items are excluded from Medicare 
coverage. 
 
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 bilateral mastopexy, augmentation 
mammoplasty bilateral and bilateral implant insertion. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had 
rupture of old silicone implants and had them replaced with a newer generation silicone implants in 2008. An 
MRI demonstrated left extracapsular silicone with suspected intracapsular rupture of the left implant. Cosmetic 
surgery to reshape the breasts to improve appearance is not a Medicare benefit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral mastopexy, augmentation mammoplasty bilateral and bilateral implant 
insertion. have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral 
mastopexy, augmentation mammoplasty bilateral and bilateral implant insertion.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve ZILRETTA injection. 
 
You asked the Plan to pre-approve the injection. You say that this drug is long-lasting and has worked in 
previous treatments. The Plan denied your request. The Plan says that this drug is not intended for repeat 
administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 
requested injection is medically reasonable and necessary. Our physician reviewer found ZILRETTA 
(triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-articular injection for 
the management of osteoarthritis pain of the knee. The product label, available at drugs@FDA, states: 
Limitation of Use:  The efficacy and safety of repeat administration of ZILRETTA have not been 
demonstrated." [see Dosage and Administration (2.1)].  Based on the Label, it does not preclude use of the drug 
more than one time.  In addition, based on the regulation 50.4.1 - Approved Use of Drug, Drugs or biologicals 
approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for 
purposes of this requirement when used for indications specified on the labeling. The documentation supports 
that ZILRETTA is medically reasonable and necessary for you and is safe and effective for you. 
 
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 ZILRETTA 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (93306) on August 6, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay the 
copayment. 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 $25 
copayment for an ultrasound.  
 
You have been asked to pay a $25 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests 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 ultrasound (93306) on 
August 6, 2020.  
 
Your complaint about the potential misinformation you received 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions and alveoloplasty provided on September 12, 
2019. 
 
You asked the Plan to pay for the extractions and alveoloplasty. You say that you had a severe infection which 
prompted your dentist to remove all of your teeth. You say that the removal of your teeth and replacement 
should be fully covered by insurance. The Plan denied your request. The Plan says the 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 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 
extractions and alveoloplasty provided on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MI profile test provided to the enrollee on July 6, 2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this is not medically necessary and cannot be approved. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found it 
has not been adequately demonstrated that the MI Profile Tumor Profiling testing has proven clinical 
validity/utility in the setting of widely metastatic high grade prostatic adenocarcinoma. Peer-reviewed full 
manuscript evidence has not been submitted. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the MI profile test provided to the enrollee on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 17, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim was denied in error. The Plan denied 
your request. The Plan says the provider is not in-network with the Plan, the services were not referred by a 
network provider or rendered in a participating facility, and the services were not urgent or emergent. 
 
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 medical services provided on August 17, 2020, 
by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that skilled services can be provided on an intermittent basis on an 
outpatient basis, in a long-term care facility, or at the home with home health care services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.