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

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where they are currently receiving car. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM receiver (K0554) provided. 
 
You asked the Plan to pay for the CGM receiver. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim has not been submitted with the 
required modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code K0554 is not supported in the record. Specifically, this claim has not been billed with 
the required modifiers to indicate whether the equipment has been rented or purchased. Additionally, this claim 
has not been billed with the required KF modifier. Based on this information, we decided that Medicare rules 
for coverage of the CGM receiver have not been met. Therefore, we decided that the Plan does not have to pay 
for the CGM receiver (K0554) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2) provided 
on July 29, 2020. 
 
You asked the Plan to pay for the custom fabricated abutments. You say that these services were provided due 
to an accident you had. 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 
custom fabricated abutments (D6057 x2) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 21, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says the referring provider did not refer these services. The Plan says 
that 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 had network providers 
available who could have provided 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 on September 21, 
2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care received on May 27, 
2020, through May 31, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You said that you are appealing these 
copays because you did not choose to go to the hospital and have surgery. The Plan denied your request. The 
Plan says the claim was 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 that enrollees must pay 
a $265 copayment per day, per stay: Days 1-7.  
 
You have been asked to pay a $265 copayment for Inpatient hospital care. 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 inpatient hospital care received on May 27, 2020, through May 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 16, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
psychotherapy 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 psychotherapy services provided on March 16, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on July 
28, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the diagnostic 
mammogram is necessary due to your history of breast cancer. 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 $100 
copayment for diagnostic procedures and tests provided in an outpatient hospital facility.  
 
Due to your personal history of cancer, the mammogram you received on July 28, 2020, is considered 
diagnostic, not preventative. Therefore, you are responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for a diagnostic mammogram. A diagnostic mammogram 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 diagnostic mammogram provided on July 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
available in-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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the 
case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on September 14, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration for the remainder 
of the charges for your hearing aid. The Plan denied your request. The Plan says coverage for up to the $800 
limit was provided. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays $800 
every 12 months for a hearing aid. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the record shows that the Plan paid $800 towards 
your hearing aid benefit. Per your EOC, you are responsible for costs beyond the $800 Plan limit. Therefore, 
we decided that the Plan does not have to pay for hearing aids provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the immunoglobulin injection provided to the enrollee. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says that the 
 
The Plan follows Medicare rules. Medicare rules say that Intravenous Immunoglobulin is covered for the 
indications listed 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 pay for the injection. Our reviewer says that the 
requested immunoglobulin injection is medically reasonable and necessary. Our physician reviewer found that 
the enrollee is a 39-year-old male with myasthenia gravis since 2015. He has received IVIG every 8 weeks 
since June 2017 with a reduction in exacerbation symptoms. Progressive myasthenia gravis was diagnosed and 
is a covered indication according to the above LCD. The records show benefit from the use of the IVIG 
treatments for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan has to pay 
for the immunoglobulin injection provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided to the enrollee on September 28, 
2020. 
 
You asked the Plan to pay for the lead wires. You say that this should be covered by the Plan. The Plan denied 
your request. The Plan says that records supporting the medical necessity of the additional lead wires were not 
submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The file indicates the enrollee has previously received lead wires within 12 months. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the lead wires provided to the enrollee on September 28, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement of lead wires in a TENS unit provided to the 
enrollee on September 17, 2020. 
 
You asked the Plan to pay for the lead wires. You say that this service is separately reimbursable. The Plan 
denied your request. The Plan says a TENS unit has been purchased in the previous twelve months. 
 
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 pay for the lead wires. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there was no indication provided as to why replacement lead wires were required 
for the TENS unit. The TENS unit was noted to have been purchased within the course of the preceding year. 
There was no indication that supplies were non-operational/non-functional and required replacement. There 
were otherwise no indications provided as to why the items under review were furnished and billed for.  
 
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 lead wires have not been met. Therefore, we decided that the Plan does not 
have to pay for replacement of lead wires in a TENS unit provided to the enrollee on September 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 22, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were admitted inpatient so 
the emergency copayment should be waived. 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 $100 
copayment for emergency care.  
 
The record shows that you were admitted under observation after receiving emergency care on August 22, 
2020. Therefore, you are responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency 
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 copayment for emergency care provided on 
August 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tuberculosis screening test provided to the enrollee on June 
18, 2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided records did not clearly describe the clinical indication besides for screening purposes. There was no 
described condition or symptoms suggesting a possible TB infection or carrier status. Therefore, this request 
will be considered not medically necessary based on the provided records. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for a tuberculosis screening test provided to the enrollee on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair from the out-of-network 
provider. 
 
You asked the Plan to pre-approve the special power wheelchair. The Plan denied your request. The Plan says 
this service is available in-network. There are no extenuating circumstances related to geographic access, 
compelling continuity of care making it medically necessary that future care come only from this provider to 
justify prior authorization of out-of-network benefits. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a special power 
wheelchair from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant, custom implant abutment, and implant 
supported crown on tooth #5. 
 
You asked the Plan to pre-approve these services. You say that you would like this to be covered. The Plan 
denied your request. The Plan says that this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant, custom implant abutment, and implant supported crown on tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional payment for the dentures provided on January 29, 
2020. 
 
You asked the Plan to approve additional payment for the dentures. You say that you were told by the provider 
they wouldn't be charging you. The Plan denied your request. The Plan says that you are responsible for any 
amount over and above the allowance amount. 
 
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 up to a $1,000 
combined allowance for supplemental preventive and comprehensive dental services every year. 
 
We looked at the file and Medicare rules. The file shows that the Plan has approved the maximum yearly 
benefit of $1,000 for the requested services. There is no provision in the contract which would require the plan 
to approve more than this amount. Therefore, we decided that the Plan does not have to approve additional 
payment for the dentures provided on January 29, 2020.