Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network podiatry 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 out of network podiatry 
services provided to the enrollee on June 30, 2020.
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 enrollee will benefit from nursing care, regular 
physician rounding, and intense therapy to build up strength. The Plan denied your request. The Plan says the 
enrollee is not able to participate in intensive therapy at this time. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for surgery for colon cancer. Her medical problems are 
stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable 
expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 
 
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 physician services provided to the enrollee on July 29, 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 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 physician services provided to the enrollee on July 
29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam you had on August 4, 2020. 
 
You asked the Plan to pay for the eye exam. You say that you needed a lens adjustment. The Plan denied your 
request. The Plan says this is only covered once per year. 
 
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 these services once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan covers routine eye exams once per calendar year. The 
records show that this was your second routine eye exam of 2020. The Plan paid for the exam you received on 
June 26, 2020. Based on this information, we decided that the Plan's rules for coverage of the eye exam have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam you had on 
August 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services 
rendered from March 26, 2019 to May 31, 2019. 
 
You asked the Plan to waive the copayments for these services. You say that the provider told you there was no 
copayment. 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 $40 
copayment for each therapy visit.  
 
Review of the file shows that you received PT services on March 26, 2019. Per the contract with the Plan, there 
is a $40 copayment for each therapy visit. However, the Medicare allowed amount for these services was 
$36.63. Given that the allowed amount was less than the $40 copayment, you have been asked to pay $36.63 
for these services. 
 
The file shows that you received PT services on March 28, 2019. Per the contract with the Plan, there is a $40 
copayment for each therapy visit. However, the Medicare allowed amount for these services was $12.27. Given 
that the allowed amount was less than the $40 copayment, you have been asked to pay $12.27 for these 
services. 
 
The file shows that you received PT for seven dates of service from April 5, 2019 to May 31, 2019. You have 
been asked to pay a $40 copayment per date of service for these services, for a total of $280. These services fall 
within the therapy visit benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan.  
 
The total amount you have been asked to pay for these services $328.90. 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 the physical therapy (PT) services rendered from March 26, 2019 to May 31, 
2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the submitted documentation does not 
support that Keytruda is reasonable and necessary or safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoAmp Allograft for posterior cervical fusion. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the OsteoAmp Allograft in the setting of posterior 
cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is indicated for inpatient C5-T1 posterior cervical fusion. He is status post prior C5-C7 
anterior cervical discectomy and fusion with reported pseudoarthrosis. Under consideration is a request for the 
use of the surgical allograft OsteoAmp (CPT code 20930). There is no evidence that OsteoAmp has been 
approved for the FDA for any indication. There is no evidence based medical literature to support the use of 
OsteoAmp in cervical fusion surgery. The use of OsteoAmp in the approved cervical surgery would be 
considered experimental or investigational and would not meet Medicare coverage criteria. Therefore, this 
request for OsteoAmp allograft (CPT code 20930) for the approved inpatient C5-T1 posterior cervical fusion is 
not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OsteoAmp Allograft for posterior cervical fusion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
August 7, 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 ordering provider is not in network and the enrollee did not have prior authorization 
for out of network services. 
 
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 lab services 
provided to the enrollee on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on May 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to you by an out-of-network provider on May 
26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided September 3, 2020 to 
September 5, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services rendered were not medically 
necessary. 
 
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 presented profoundly hyponatremic. The sodium of 122 on admission alone meets 
criteria for admission where it would be reasonably felt that the hospitalization would last 2 or more midnights. 
Therefore, the enrollee met criteria for the inpatient services rendered. 
 
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 September 3, 2020 to September 5, 2020.  
 
 
 
 
 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the vitamin B12, ferritin, folic acid, and C-reactive 
protein testing provided on January 22, 2020. 
 
You asked the Plan to hold you harmless for the lab testing. You say that you feel that this should be covered. 
The Plan denied your request. The Plan says that no payment can be made because these lab tests are not 
payable by Medicare. 
 
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 provided with the lab testing by a contract provider. This was billed with modifier - 
GY which is not appropriate for this service as this test is not statutorily excluded by Medicare regulation. The 
file does not show that the Plan provided notice that the lab testing would not be covered. Under Medicare 
rules, this means the lab testing is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for the vitamin B12, ferritin, folic acid, and C-reactive protein testing provided on January 
22, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 9, 
2020 to February 19, 2020 by an out of network (OON) facility. 
 
You asked the Plan to pay for the OON inpatient care. You say that it is felt that the medical records support 
payment of this claim. The Plan denied your request. The Plan says these non-emergent hospital services were 
provided without obtaining authorization. No authorization was requested until over a week into the hospital 
stay. As such, this claim was correctly denied. 
 
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 inpatient hospital services provided from 
February 9, 2020 to February 19, 2020 by an out of network (OON) facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Life Vest provided on December 11, 
2019 and February 11, 2020. 
 
You asked the Plan to waive the coinsurance for the Life Vest. 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 a Life Vest on the dates of service at issue in this appeal. The Plan 
says that the correct coinsurance 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 20% 
coinsurance for Durable medical equipment.  
 
We looked at the file, the Plan's contracts and Medicare rules. The file shows that you received a Life Vest on 
December 11, 2019 and February 11, 2020. You have been asked to pay a 20% coinsurance for the Life Vest 
for each date of service, totaling $579.90 for the December 11, 2019 date of service and $585.12 for the 
February 11, 2020 date of service. The Life Vest falls within the Durable medical equipment 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 that 
the Plan does not have to waive the coinsurance for the Life Vest provided on December 11, 2019 and 
February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) and a consultation 
(D9310) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your general dentist referred you to an oral 
surgeon for these services. You say that your dentist advised that your upper jawbone might get infected if 
teeth # 3 and # 14 are not extracted. The Plan denied your request. The Plan says services must be performed 
by a participating general dentist. The Plan also says that services from an oral surgeon 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 2 
surgical extractions (D7210) and a consultation (D9310) to be provided by an oral surgeon.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $175 copayment for ambulance transport provided on June 
17, 2020. 
 
You asked the Plan to waive this copayment. You say that you should not be responsible for these copayments 
because the provider caused your health issues. The Plan denied your request. The Plan says these copayments 
were charged based on the services provided and the Plan contract agreement. 
 
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 $175 
copayment for each one-way ambulance transport. 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 $175 copayment for ambulance 
transport provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim partial denture (D5820). 
 
You asked the Plan to pre-approve the dental item. You say that you had 2 teeth extracted. You say that you 
need a partial denture flipper to be approved otherwise you will be missing dentures. The Plan denied your 
request. The Plan says the requested interim partial denture is not listed as a covered service. 
 
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 the 
interim partial denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on July 28, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you think you may have been billed incorrectly. 
You say that you went to the dentist in January and the cost was covered. You say that now the services are 
being denied. You also say that the provider is listed as in network in the book. The Plan denied your request. 
The Plan says 2 oral exams are covered every year. The Plan says that the frequency limit has been exceeded. 
The Plan also says that payment was made for the oral exams that you received on January 21, 2020, and June 
15, 2020. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 2 oral exams per 
year has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120) provided on July 28, 2020.