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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 17, 2019, to June 
19, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with records. The 
Plan denied your request. The Plan says that the denial of payment for this inpatient stay is correct. 
 
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 the enrollee had a history of recently diagnosed adenocarcinoma of the lungs with metastasis, 
atrial fibrillation, SIADH and recent upper gastrointestinal bleeding with hospitalization from June 15, 2019, to 
June 17, 2019. She was in a skilled nursing facility when she complained of dizziness and lightheadedness and 
was brought to the emergency room by ambulance. She was admitted and evaluated by cardiology. She was 
then stabilized and discharged to an assisted living facility on June 20, 2019 with plan to transition to hospice. 
Review has determined that this re-admission was medically necessary and did not result from a premature 
discharge from the same hospital. 
 
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 June 17, 2019, to June 19, 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 pay for out of network physician services provided on May 13. 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 out of network physician services provided on May 13. 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided by 
a participating provider on January 3, 2020, to January 6, 2020. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you were never 
told that you would have this copayment. The Plan denied your request. The Plan says the correct copayments 
have 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 $25 
copayment for cardiac rehabilitation services/in-network.  
 
You have been asked to pay a $25 copayment for each cardiac rehabilitation service. The total amount you are 
being asked to pay is $50 ($25 x 2 visits = $50). Cardiac rehabilitation services fall within the cardiac 
rehabilitation services/in-network 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 
cardiac rehabilitation services provided by a participating provider on January 3, 2020, to January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99212) on January 
6, 2020, and a closure of tear ducts (68761) performed on January 15, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and a closure of tear ducts. You say 
that these services should be covered in full. The Plan denied your request. The Plan says the correct 
copayments were 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 $50 
copayment for physician specialist services.  
 
You have been asked to pay a $42 copayment for a specialist office visit and a $50 copayment for a closure of 
tear ducts. A specialist office visit and a closure of tear ducts fall within the "Physician/Practitioner services, 
including doctor's office visits" benefit category. This means that you have been asked to pay less than or equal 
to the full copayment 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 office visit (99212) on January 6, 2020, and a closure of tear ducts (68761) 
performed on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on May 7, 2020. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says a root canal was 
performed through a crown, and the crown was not being replaced. The Plan also says that the core buildup is 
not covered because it was not done along with a new crown. 
 
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, core buildup, including any pins when 
required (D2950) has to be performed together with a crown. The records show that a crown was not provided 
on this date of service. Therefore, we decided that the Plan does not have to pay for the core buildup, including 
any pins when required (D2950) provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the services. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. It is not medically needed. There is no instability documented. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay on April 11 to 
April 12, 2020. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that this bill is extremely 
high for a one-night stay for a must-have treatment. The Plan denied your request. The Plan says the correct 
coinsurance was 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 15% 
coinsurance for each Medicare-covered hospital stay.  
 
You have been asked to pay $1,075.51, or less than 15% coinsurance of the Plan-allowed amount of $9,653.28, 
for an inpatient hospital stay. An inpatient hospital stay falls within the "Inpatient Hospital Care" benefit 
category. This means that you have been asked to pay less than the full coinsurance 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 coinsurance for an inpatient hospital stay 
on April 11 to April 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit for observation (D9430) provided on May 22, 2020.You asked the Plan to pay forthe office visit for observation. You say that you had your dentures adjusted, and were not told that the services were not covered.The Plan denied your request. The Plan says this service is not covered under your 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 fortheoffice visit for observation (D9430) provided on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assay of Natriuretic peptide provided on February 3, 
2020. 
 
You asked the Plan to pay for the assay of Natriuretic peptide. You say that you would like the plan to 
reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 assay of Natriuretic peptide testing at issue in this appeal 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 assay of Natriuretic peptide provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided to the enrollee on January 28, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met.  
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for testing provided to the enrollee on January 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided out of network
May 19, 2020 to June 24, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network
chiropractic 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 out of network chiropractic
services provided out of network May 19, 2020 to June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and problem focused limited oral evaluation provided on June 5, 2020.

You asked the Plan to pay for the endodontic therapy. You say that this service is a covered benefit. The Plan denied your request. The Plan says this service is not a covered benefit.

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 endodontic therapy and problem focused limited oral evaluation provided on June 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan has to waive the copayments for cardiac rehabilitation from September 4, 2019, to September 25, 2019.

You asked the Plan to waive the copayments for cardiac rehabilitation. You say that you did not receive the services and disagree with the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether services were rendered or not. Therefore, we decided that the Plan has to waive the copayments for cardiac rehabilitation from September 4, 2019, to September 25, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip replacement (27130). 
 
You asked the Plan to pre-approve the hip replacement. You say that the hip replacement is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that hip arthroplasty is covered when 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 hip replacement. Our reviewer says 
that the requested procedure is not medically necessary. Our physician reviewer found there is no advanced 
right hip joint degenerative disease demonstrated on radiographic studies. There is no evidence that 
conservative treatment, including physical therapy or exercise, had been tried and failed. Therefore, this request 
for total hip arthroplasty is not medically reasonable and necessary at this time. 
 
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 hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip replacement (27130).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic hereditary predictive screening testing
provided on April 20, 2020.
You asked the Plan to pay for the molecular genetic hereditary predictive screening testing. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered are not a covered benefit.
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 molecular genetic hereditary predictive screening testing at issue in this appeal 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 molecular genetic hereditary predictive screening testing provided on
April 20, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal pain and treated for 
an intestinal infection. Your medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on May 23, 2020. 
 
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
chiropractic treatment. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for chiropractic treatment provided on May 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health skilled nursing visits. 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 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 skilled nursing visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's 
condition and/or prevent deterioration. The enrollee has had prior skilled nursing for disease and medication 
management and education. The enrollee's conditions are chronic and there is no evidence of complex wound 
care or other skilled nursing need. 
 
 
 
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 skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing visits.