Persius/hicric huggingface dataset:
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 29, 2020 to 
May 9, 2020. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the 
enrollee must receive services by a provider who is eligible to participate in Medicare. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under original 
Medicare. 
 
The provider in this case is not a network provider with the Plan. The provider at issue is also not eligible to 
participate in Medicare. The Plan has network providers available who can provide the home health 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 
home health services provided on March 29, 2020 to May 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography (77066, G0279) provided on January 10, 
2020. 
 
You asked the Plan to pay for mammography. You say that this was billed correctly. The Plan denied your 
request. The Plan says the documentation does not support these codes. 
 
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 CPT Code Manual definition of code 77066 is diagnostic mammography, including computer-
aided detection (CAD) when performed; bilateral and G0279 is diagnostic digital breast tomosynthesis, 
unilateral or bilateral (list separately in addition to 77065 or 77066). 
 
We find that CPT codes 77066 and G0279 are not supported in the medical record. Specifically, the file shows 
that a unit of 77066 was previously paid for this provider and date of service. The records do not support that a 
second mammography was performed. Because the primary procedure, 77066, is not supported, the add-on 
code G0276 is also not supported. Based on this information, we decided that Medicare rules for coverage of 
mammography have not been met. Therefore, we decided that the Plan does not have to pay for mammography 
(77066, G0279) provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for non-sterile gloves (A4927) contact layer, sterile dressing 
(A6207) self-adherent bandage, elastic (A6455) provided March 24, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that you are appealing the out of network 
deductible for DME supplies. You did not have a choice where the supplies were ordered and you feel that this 
should be billed as in network. The Plan denied your request. The Plan says the correct cost share was applied 
per the plan benefits. You are liable for the $71.30 paid toward the annual deductible for any out of network 
services before the plan will pay toward a claim. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a 20% coinsurance after the deductible for each DME item, and a $250 
deductible for out of network services. Until you have paid the deductible amount, you must pay the full cost 
for most of your out of network covered services 
 
The item or service you asked the Plan to pay for falls within the benefit category Durable medical equipment 
(DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that 
your yearly out of network deductible is $250. Until you have paid the deductible amount, you must pay the 
full cost for most of your out of network covered services. This cost sharing is a contractual obligation that had 
not been met at the time the medical supplies was received on March 24, 2020. Therefore, we decided that the 
Plan does not have to pay for non-sterile gloves (A4927) contact layer, sterile dressing (A6207) self-adherent 
bandage, elastic (A6455) provided March 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewings (D0274) provided on June 23, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewings 
(D0274). You say that you contacted the Plan and understood that you could cancel and reinstate your dental 
coverage. You also say that you originally had an appointment in April, but the office had closed because of the 
pandemic, and your appointment was rescheduled. The Plan denied your request. The Plan says you are not 
eligible for coverage. The Plan also says that you were enrolled into the 2020 Platinum Dental Rider effective 
April 1, 2020, through May 31, 2020. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The record shows that your Platinum Dental Rider enrollment was terminated on May 31, 
2020. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), 
prophylaxis (D1110), and bitewings (D0274) provided on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 4, 2020, to 
January 25, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that care could have provided at a lower level. 
 
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 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 that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from January 4, 2020, to January 25, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scale for a hospital bed. 
 
You asked the Plan to pre-approve the hospital bed scale. You say that a scaling system would be helpful to 
monitor for signs of fluid overload in order to adjust medications and prevent hospitalization. The Plan denied 
your request. The Plan says the bed scale is not medically needed for the enrollee's care. 
 
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. While a bed scale 
may be helpful, it does not directly diagnose or treat a medical condition. Therefore, we decided that the Plan 
does not have to pre-approve a scale for a hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam with refraction you received on June 4, 2020. 
 
You asked the Plan to pay for the exam. You say that this should be covered. The Plan denied your request. 
The Plan says the benefit limit has been exceeded. 
 
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 when once per calendar year. 
 
We looked at the file and the Plan's rules. The records show that you received a covered refraction exam on 
May 29, 2020. This service is only covered once per year. The requested services exceed the benefit limit. 
Based on this information, we decided that the Plan's rules for coverage of the requested exam have not been 
met. Therefore, we decided that the Plan does not have to pay for the eye exam with refraction you received on 
June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided out of network on May 21, 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 physician services provided out of network on May 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that there are no contracted provided that could 
have provided the services in a mobile setting. 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 on June 11, 2020 by an out of network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the electrocardiogram (EKG) services 
rendered on May 6, 2020 and May 19, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that the services should have 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 $15 
copayment for each in-network outpatient non-radiological diagnostic service at a specialist office.  
 
Review of the file shows that you received EKG services on May 6, 2020 and May 19, 2020. You have been 
asked to pay a $15 copayment per date of service for these services, for a total of $30. These services fall 
within the in-network outpatient non-radiological diagnostic service at a specialist office 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 the electrocardiogram (EKG) services rendered on May 6, 
2020 and May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the health and wellness services you received on April 21, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you did not submit 
proof of payment. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services 
only if you submit a Wellness Allowance reimbursement form with proof of payment.. 
 
The Plan's rules for coverage of gym benefits have not been met because you did not submit proof of payment 
for these services. Therefore, we decided that the Plan does not have to pay for the health and wellness services 
you received on April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that an overnight stay is necessary. The 
Plan denied your request. The Plan says that you do not require inpatient care. 
 
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 pre-approve inpatient hospital care. Our reviewer 
says that the documentation does not support that inpatient hospital care is medically reasonable and necessary 
in this case. You do not have any documentation of co-morbid conditions requiring inpatient care and no 
documentation of anticipated surgical or anesthetic complications or that you have a high post-anesthetic or 
drug-related risk. Our physician reviewer found that the record does not show that at the time of inpatient 
admission the admitting physician reasonably expects that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

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

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

We decided that the Plan does not have to waive the copayment for computed tomography (CT) soft tissue 
neck; with contrast material (70491) provided March 16, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you strongly feel that you should not 
have to pay for it. You were told at the doctor's office that you would have no payment with your coverage. 
The Plan denied your request. The Plan says the copayment was applied correctly per the plan benefits. 
 
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 $60 
copay for covered complex diagnostic radiological services.  
 
You have been asked to pay $60 copay for the CT scan. The CT scan 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 computed tomography (CT) soft tissue neck; with contrast material (70491) provided March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 4, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician for the billed test. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
G0483 provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower/tub. 
 
You asked the Plan to pre-approve a walk-in shower/tub. You say that this is medically necessary. The Plan 
denied your request. The Plan says that hygienic equipment is not covered as it is not primarily medical in 
nature. 
 
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 walk-in shower/tub.