Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, 
the health plan?s denial should be upheld. You do not require the intensity of services provided at an IRF. 
Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative 
services with regular physician evaluation. Your 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 IRF admission and services.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, 
the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to be able to currently perform fifteen hours per week of 
rehabilitative 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 IRF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 8, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician?s services. 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 physician's services provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on December 
5, 2017. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you have never paid for a 
breast ultrasound in the past because it was covered as preventative. 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 $0 
copayment for mammography tests performed on the same date of service as the corresponding preventative 
test and a $50 copayment for all other services. 
 
You received a breast ultrasound on December 5, 2017. The record shows that you received a mammogram 
screening on November 20, 2017. Therefore, you are responsible to pay a $50 copayment for the ultrasound.   
 
You have been asked to pay a $50 copayment for a breast ultrasound. A breast ultrasound falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 a breast ultrasound provided on December 5, 2017.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest provided on July 23, 2020 and billed 
under claim number 820202310015990. 
 
You asked the Plan to pay for the x-ray of the chest. You say that the enrollee had multiple exams on the date 
of service and the reports submitted support the level of care. The Plan denied your request. The Plan says the 
records and documents received do no support that CPT 71045 was performed more than once by the doctor 
who is billing for the date of service in dispute. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must furnish sufficient information to 
determine whether payment is due and the amount of payment. Medicare rules also say that claims or claim 
lines that have been determined to be exact duplicates of another claim or claim line will be denied. 
 
We looked at the file and Medicare rules. The medical records do not support that more than one x-ray was 
supplied by the billing provider on the date of service in dispute. The records show that the Plan already paid 
for the one x-ray that was supplied by the billing provider on July 23, 2020. Based on this information, we 
 
 
decided that Medicare rules for coverage of the x-ray of the chest have not been met. Therefore, we decided 
that the Plan does not have to pay for an x-ray of the chest provided on July 23, 2020 and billed under claim 
number 820202310015990.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment for emergency room services provided on March 4, 2020.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The appeal states urgent care services in your area do not have the resources to treat eye emergencies. You are requesting an exception in this case. The Plan denied your request. The Plan says this copayment was charged per the Plan contract agreement and the claim submitted by the provider.

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 $50 copayment for emergency room services. 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 $50 copayment for emergency room services provided on March 4, 2020
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on February 12, 2020, to May 
13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. 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. 
 
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 outpatient surgery provided on February 12, 2020, 
to May 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized automatic chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor does not document this item as included in the course of treatment. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 chair. Our reviewer says that the 
requested chair is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not reveal objective evidence that you have severe arthritis of the hip. The documentation does not reveal that 
you have a neuromuscular disease.  The documentation does not support that a seat lift is likely to effect 
improvement in your condition or arrest or retard deterioration in the patient's condition. The records do not 
indicate that you are completely incapable of standing from a chair in the home on a physical exam. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a motorized automatic chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation (99442) provided on May 26, 2020. 
 
You asked the Plan to pay for a telephone evaluation. You say that this was billed correctly. The Plan denied 
your request. The Plan says the billed procedure and diagnosis codes do not support each other. 
 
The Plan must follow Medicare rules. Medicare rules say that a procedure code is required to confirm that the 
screening indicated by screening Z codes was performed.   
 
We looked at the file and Medicare rules. This claim was billed with a diagnosis code Z12.2, encounter for 
screening for malignant neoplasm of respiratory organs, but it does not include a procedure code indicating the 
screening took place. Based on this information, we decided that Medicare rules for coverage of a telephone 
evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a telephone 
evaluation (99442) provided on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab work to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve lab work. You say that you would like this claim approved. The Plan denied 
your request. The Plan says there are in-network providers available for these 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lab work to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a queen sized mattress and box spring. 
 
You asked the Plan to pre-approve a queen sized mattress and box spring. You say that you need a queen sized 
mattress and box spring to alleviate you back pain. The Plan denied your request. The Plan says a queen sized 
mattress and box spring are not primarily and customarily used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a queen sized mattress and box spring.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
December 10, 2019, to February 4, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you 
would only owe $4.80 per each infusion but now you are being charged $36. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. Medicare Part B drugs fall within the 
Medicare Part B prescription drugs 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 
Medicare Part B drugs provided from December 10, 2019, to February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that gauze or other dressings, gel sheets, and tape are 
non-covered. 
 
We looked at the file and Medicare rules. The services at issue are wound care supplies that do not meet the 
definition of a covered surgical dressing. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
wound care supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 6, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that the orthotics were necessary due to the pain in your 
feet.  The Plan denied your request. The Plan says you do not suffer from severe diabetic foot disease.  
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from severe diabetic foot disease and you do not wear a leg brace. 
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 
6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing of the lower right and lower 
left quadrants (D4341 x 2). 
 
You asked the Plan to pre-approve these services. You say that the patient will significantly benefit from 
scaling and root planing as there is significant bone loss and bleeding of the gums. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for coverage of this procedure. 
 
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. The Plan covers these 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 these services. Our reviewer says that 
the request for periodontal scaling and root planing of the mandibular left and right quadrants meets the criteria 
for coverage. Our physician reviewer found that a review of the patient's dental record and radiographs indicate 
that periodontal scaling and root planing has been approved for the maxillary arch. The documentation 
provided indicates that bone loss, pathological periodontal pocketing and bleeding when probed exist in the 
mandibular arch.  
 
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 these services have been met. Therefore, we decided that the Plan has to pre-
approve periodontal scaling and root planing of the lower right and lower left quadrants (D4341 x 2).  
 
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 skilled nursing services provided on September 28, 2019 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  
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring facility 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 September 
28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for insertion or replacement of spinal 
neurostimulator pulse generator or receiver, direct of inductive coupling (63685) provided on October 8, 2019 
through October 15, 2019. 
 
You asked the Plan to waive the coinsurance for insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct of inductive coupling. You say that the cost share is incorrect. The Plan denied 
your request. The Plan says the cost share is correct. 
 
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 outpatient hospital services.  
 
You have been asked to pay a 20% coinsurance for insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct of inductive coupling. This service falls within the outpatient hospital 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 coinsurance for insertion or replacement of 
spinal neurostimulator pulse generator or receiver, direct of inductive coupling (63685) provided on October 8, 
2019 through October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 22, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the member was not referred by their primary care 
physician for these services and the services were not 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 April 22, 2020, 
by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mastopexy provided on December 4, 2019. 
 
You asked the Plan to pay for the Mastopexy. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says Medicare rules for payment of this claim have not been met. 
 
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 19316 is 1. You billed the bilateral procedure separately, exceeding the 
MUE. Based on this information, we decided that Medicare rules for coverage of Mastopexy have not been 
met. Therefore, we decided that the Plan does not have to pay for the Mastopexy provided on December 4, 
2019.