Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the various X-ray images and unspecified preventative 
procedure (D1999, D0274, D0230, D0220) provided on June 24, 2020. 
 
You asked the Plan to pay for the various X-ray images and unspecified preventative procedure. You say that 
you were not told individual X-rays were not covered. The Plan denied your request. The Plan says the 
procedures you received are not covered according to the EOC. 
 
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 case file indicates the specific dental services which are covered 
as a supplemental benefit. The dental services being billed are not covered under the Plan's supplemental 
coverage. It is noted that the plan is offering $10 credit for the unspecified preventative procedure. Therefore, 
we decided that the Plan does not have to pay for the various X-ray images and unspecified preventative 
procedure (D1999, D0274, D0230, D0220) provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge for teeth #12-14. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no indication why dentures cannot be used to replace the missing 
teeth. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the requested services are not medically reasonable or necessary. Our physician reviewer found there has 
been no submission of any physical or neurological disorder in the record. The limitations of the Plan does not 
allow for this type of treatment plan however unless the stated criteria has been met, and in this case there 
would be no necessity for the requested procedures. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dental bridge for teeth #12-14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 18, 2020, to 
March 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring provider is also out-of-network. 
 
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 skilled nursing services provided on February 18, 
2020, to March 25, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from July 10, 
2020, through July 30, 2020. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you were informed your 
copayments would be waived because of the pandemic. You say that the provider should be able to write off 
the copayments. The Plan denied your request. The Plan says the copayments 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 Medicare-covered physical therapy from an in-network provider. 
 
You have been asked to pay a total of $197.73 for physical therapy.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
July 10, 2020 Physical Therapy $82.52 $40 $40 
July 14, 2020 Physical Therapy $75.46 $40 $40 
July 17, 2020 Physical Therapy $135.96 $40 $40 
July 21, 2020 Physical Therapy $135.96 $40 $40 
July 30, 2020 Physical Therapy $37.73 $40 $37.73 
TOTAL:    $197.73 
 
Physical therapy falls 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 physical therapy provided from July 10, 2020, through July 30, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that treating the enrollee with this drug is medically 
appropriate and necessary, and should be a covered service. The Plan denied your request. The Plan says that 
iron studies from within the last 90 days, including Transferrin saturation, Serum Ferritin, and Iron, along with 
medical records indicating the enrollee previously tried oral iron or is intolerant to oral iron were not submitted. 
The Plan also says that the documentation does not support the medical necessity of this drug. 
 
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 Feraheme. Our reviewer says that 
Feraheme is medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has documented iron deficiency anemia and falling hemoglobin with low iron indices. Our reviewer also found 
that intravenous iron is indicated 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 Feraheme have been met. Therefore, we decided that the Plan has to pre-
approve Feraheme.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the psychiatric and psychological 
evaluations provided on July 28, 2020. 
 
You asked the Plan to waive the coinsurance for the psychiatric and psychological evaluations. You say that 
you weren't informed the provider was out-of-network or how much it would cost out-of-pocket. You say that 
you were billed as it was an office visit, but this was a telehealth appointment. The Plan denied your request. 
The Plan says the coinsurance 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 40% 
coinsurance for outpatient mental health care at an out-of-network specialist's office. 
 
You have been asked to pay $211.61, which is 40% of the allowed amount for the psychiatric and 
psychological evaluations. The allowed amount is $529.02 (40% x $529.02 = $211.61). The psychiatric and 
psychological evaluations fall within the "Outpatient mental health 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 coinsurance for the psychiatric and psychological evaluations provided on July 28, 
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 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 is already ambulating household distances. 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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided. 
 
You asked the Plan to pay for this service. You say that the inpatient hospital care provided was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the inpatient hospital care provided 
was 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 the 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 that due to the given presentation and the severity of baseline medical problems, it was 
reasonable to feel that two or more midnights would have been necessary at the time of admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital care provided.  
 
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 pre-approve a Stretta procedure. 
 
You asked the Plan to pre-approve Esophagogastroduodenoscopy (43257). You say that the enrollee needs this 
procedure. The Plan denied your request. The Plan says this procedure is not covered for treatment of 
gastroesophageal reflux disease. 
 
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 Esophagogastroduodenoscopy (43257). 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Stretta procedure is an excluded/ non-covered service per provided 
medical policy. The procedure is not medically necessary and is relatively contraindicated in the enrollee's 
circumstance of dysphagia -- likely a result of both known esophageal dysmotility in the setting of Parkinson's 
disease, and known esophageal stricture which responded to dilation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Esophagogastroduodenoscopy (43257) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Stretta procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit and nasal endoscopy 
provided on July 2, 2020 and August 4, 2020. 
 
You asked the Plan to waive the copayment for the office visit and nasal endoscopy. You say that these were 
follow-up visits from a previous procedure and should be covered with no cost. The Plan denied your request. 
The Plan says the copayments 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 $30 for 
each visit to a specialty physician office.  
 
You have been asked to pay a $30 copayment for the office visit and a $30 copayment for the nasal endoscopy. 
The office visit and nasal endoscopy fall within the "Physician/Practitioner services, including doctor?s office 
visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for 
a service performed as a follow-up to a procedure. 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 office visit and nasal endoscopy provided on July 2, 2020 and August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) 
nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that the literature shows this has positive effect 
for postop knee pain and arthritis. The Plan denied your request. The Plan says until the medical studies in the 
current pipeline have reported results which definitively show this treatment to be 
beneficial as a treatment for osteoarthritis or to avoid or significantly delay knee replacement, it is not 
reasonable or necessary for Medicare to cover the service. 
 
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 RFA procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral knee arthritis for which he takes Lyrica and Norco. There is no 
documentation of the number of Physical therapy visits. The patient had two diagnostic sets of Left genicular 
nerve blocks which produced 70-80% pain relief. The request is for RFA of the genicular nerves. This is 
considered an experimental/investigational procedure at this time. Therefore, the request is considered not 
medically reasonable or 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 RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be equally well-received in another setting, such as discharge to SNF 
with skilled therapy. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical treatment of a hip fracture. 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. 
 
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).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 
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 due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on March 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies provided on January 9, 2020. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says these items are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not 
limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately 
for ambulance services.  
 
We looked at the file and Medicare rules. Supplies provided during ambulance transport are not paid 
separately. Payment for these items are included in the payment for the ambulance transport. Based on this 
information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulance supplies provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injection provided on July 9, 2020. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the procedure. 
The Plan denied your request. The Plan says the code exceeds the allowable unit of service for the date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64493 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the facet joint injection provided on July 9, 2020.