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

 
We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from 
January 22, 2020 to January 23, 2020. 
 
You asked the Plan to waive the copay for the inpatient hospital services. The Plan denied your request. The 
Plan says that the claim processed 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 $325 
copay per day, days 1-6 of Inpatient hospital care.  
 
You have been asked to pay a $650 copay for the inpatient hospital services. The inpatient hospital services fall 
within the days 1-6 of Inpatient hospital 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 copay for 
the inpatient hospital services provided from January 22, 2020 to January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The records show that the services in question were billed on a 
duplicate claim to services previously processed for payment by the Plan. As a duplicate claim, the services are 
not payable. 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 pay for the services provided on April 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, and retreatment of previous root canal therapy provided on April 17, 2020 by a Medicare opt 
out provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
retreatment of previous root canal therapy. You say that you do not understand why the Plan will not pay for 
these services. The Plan denied your request. The Plan says these services were rendered by a provider who has 
formally opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation, first intraoral periapical x-ray, and retreatment of previous root 
canal therapy provided on April 17, 2020 by a Medicare opt out provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest x-ray. 
 
You asked the Plan to pre-approve a chest x-ray. The Plan denied your request. The Plan says your PCP did not 
order an x-ray. 
 
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 a chest x-ray. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee in this case is a 69-year-old female with COPD who was complaining of 2 
weeks of a cough on June 4, 2020. Her lungs were clear to auscultation. The documentation from this date did 
not include plans for an x-ray, nor an indication for such. The provided records do not include a formal order or 
requisition form for an x-ray to justify this request. Therefore, without justification made for this request, this 
request for a chest x-ray will be considered not medically 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 a chest x-ray have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a chest x-ray.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the records 
show that the enrollee has a 28.5 pack/year history of smoking, but quit more than 3 years ago. He is not 
reporting any symptoms suggestive of a lung condition present currently. A CT scan of the chest from 
December 14, 2017, showed a 2 mm nodule, unchanged from prior CT scan from December 28, 2016. The 
enrollee has less than a 30 pack/year history and is not currently smoking, which does not meet current 
guidelines and criteria. With no change in imaging in recent years, and no current symptoms or significant 
enough risk factors, a repeat CT scan is not indicated here. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the chest.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on February 27, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you did not get treated for 
anything. The Plan denied your request. The Plan says the copayment was 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 $120 
copayment per visit for all Medicare-covered emergency care services.  
 
Review of the file shows that you received ER services on February 27, 2020. The records show that you 
received treatment for a fever for two days, a sore throat, left ear bleed, cough, and congestion. You have been 
asked to pay a $120 copayment for these services. These services fall within the all Medicare-covered 
emergency care 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 copayment for the 
emergency room (ER) services rendered on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with leg pain after spine surgery and incision and drainage of a hematoma. He received oral and inhaled 
medications and had stable vital signs. He received physical and occupational therapy in the hospital and needs 
standby to minimal assistance with functional mobility, including gait to 450 feet with a rolling walker. He 
needs varied assistance with activities of daily living. He has no skilled nursing needs. He has skilled therapy 
needs, but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require 
the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (CPT 82570) provided on January 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the physician's 
requisition for laboratory testing shows this test was not ordered by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the testing be performed. 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 pay for the lab 
services (CPT 82570) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 20, 
2019. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were told that your only 
obligation for this visit was $45 copayment, and you should not be responsible for this additional amount. The 
Plan denied your request. The Plan says the copayment amount you are being charged 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 $295 
copayment for outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay the allowed amount of $253.82, which is less than the $295 copayment for 
outpatient surgery. Outpatient surgery falls within the Outpatient Surgery and Other Medical Services Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery provided on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 17, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 pay for the drug testing rendered on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syvnisc. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee pain. There is 
no evidence that prescription medications, steroid injections, home exercise or physical therapy/occupational 
therapy have been used to treat the knee pain. She has not tried and failed the Plan's required drugs of 
Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, the Synvisc is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Syvnisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on November 3, 2019. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that critical care is a time- based service, and for each 
date and encounter entry, the physician's progress note(s) shall document the total time that critical care 
services were provided. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 
amount of time spent rendering critical care services on the billed date of service. Based on this information, 
we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on November 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on May 29, 
2019. 
 
You asked the Plan to pay for home health services. You say that this should be paid. The Plan denied your 
request. The Plan says a final claim was not submitted. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. If the claim is not received 60 days after the 
calculated end date of the episode (day 120) or period (day 90) or 60 days after the paid date of the RAP 
(whichever is greater), the RAP payment will be canceled automatically by Medicare claims processing 
systems. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not show that a final claim was submitted within the appropriate timeframe following the payment of the 
RAP. Therefore, we decided that the Plan does not have to pay for the home health services provided to the 
enrollee on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2740 x2) provided on January 15, 2020. 
 
You asked the Plan to pay for the crowns. You say that you contacted the Plan prior to receiving these services, 
and were told that crowns and bridges would be covered at 50%. The Plan denied your request. The Plan says 
this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
crowns (D2740 x2) provided on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services rendered 
on February 5, 2020 and the wrist orthosis rendered on February 14, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was 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 $260 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital and a 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies. 
 
Review of the file shows that you received outpatient surgical services to your wrist on February 5, 2020. You 
have been asked to pay a $260 copayment for these services. These services fall within the Medicare-covered 
surgery or other services provided to you at an outpatient hospital benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received a wrist orthosis on February 14, 2020 (billed with procedure code L3906). 
You have been asked to pay a 20% coinsurance for these services, for a total of $89.40. These services fall 
within the Medicare-covered durable medical equipment and related 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 cost sharing for the outpatient surgical services rendered on 
February 5, 2020 and the wrist orthosis rendered on February 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the neuromuscular reeducation (97112), 
speech therapy (92507), therapeutic activities (97530), self-care/home management training (97535), 
evaluation of speech and sound production (92523), physical therapy evaluation (97163), and the occupational 
therapy evaluation (97167) provided January 17, 2020 to March 16, 2020. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each Medicare-covered physical, occupational, and speech language therapy visit.    
 
You have been asked to pay a $700 copayment ($25 copay x 28 treatments) for the outpatient therapy services 
provided. 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 adjust the copayment for the neuromuscular reeducation (97112), speech 
therapy (92507), therapeutic activities (97530), self-care/home management training (97535), evaluation of 
speech and sound production (92523), physical therapy evaluation (97163), and the occupational therapy 
evaluation (97167) provided January 17, 2020 to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the 
provider is not contracted by the plan, there is no evidence that the member's life was at risk, no medical 
emergency, no PCP referral and no prior authorization request. 
 
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 April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite provided by an out-of-
network provider on February 6, 2020. 
 
You asked the Plan to pay more for the resin-based composite. You say that you were informed the average 
cost of repair was $113. You say that you aren't happy with the amount paid by insurance. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay 45% 
of the allowed amount for the resin-based composite. You are responsible for the remaining amount.
 
Therefore, we decided that the Plan does not have to pay more for the resin-based composite provided by an 
out-of-network provider on February 6, 2020.