Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
June 26, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 subsequent nursing facility visit (99308) 
provided on June 26, 2019, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation services and the electrocardiogram services 
provided on April 3, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the observation services and the electrocardiogram services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit when provided by an OON provider. 
 
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 observation services and the electrocardiogram 
services provided on April 3, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRA scan of the head (70544) 
performed on August 4, 2020. 
 
You asked the Plan to waive the copayment for an MRA scan of the head. You say that you just don't have this 
type of money. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $250 
copayment for each day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for an MRA scan of the head. An MRA scan of the head 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 an MRA scan of the head (70544) performed on August 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services (CPT 99285) provided to the enrollee on 
April 3, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting additional services which were billed and 
remain denied. 
 
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 99285 is "emergency department visit for the evaluation 
and management of a patient." 
 
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 services. Our reviewer says that the 
services at issue in this case are not supported by the medical records. Our physician reviewer found evidence 
of only only one ED visit, starting on 4/3/2020 and resulting in a psychiatric admission on 4/4/2020, has been 
submitted for review. While this record indicates that the enrollee had been to the ED multiple times in the 
prior forty-eight hours, records for these other visits have not been submitted for review. Specifically, there is 
no evidence that the enrollee had a second ED visit on 4/3/2020. Therefore, the submitted documentation does 
not support the billing of two ED visits on 4/3/2020. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency services (CPT 99285) provided to the enrollee on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic test provided on February 7, 
2020. 
 
You asked the Plan to waive the copayment for a diagnostic test. You say that you cannot afford a $75 
copayment for each visit. 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 diagnostic bone mass measurements, colonoscopies and mammograms and a $100 copayment 
for all other services.  
 
You have been asked to pay the allowed amount of $74.75, which is less than the $100 copayment for a 
diagnostic test. A diagnostic test 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 test provided 
on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99335) provided on May 28, 2020 to 
June 15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that medically necessary services were provided in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 domiciliary visit (99335) provided on May 28, 
2020 to June 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair and walker provided on June 5, 2020. 
 
You asked the Plan to pay for the services provided. You say that the items facilitated your movement until 
after your home therapies began. The Plan denied your request. The Plan says the provider is not listed as an 
acceptable provider. 
 
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, and is not eligible to provide services under 
Original Medicare. 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 
wheelchair and walker provided on June 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic CT scan of the thorax (71250) 
performed on June 3, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic CT scan of the thorax. You say that this service 
was only a screening. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $250 
copayment for each day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $92.94 copayment for a diagnostic CT scan of the thorax. A diagnostic CT scan 
of the thorax falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit 
category. This means that you have been asked to pay less than or equal to 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 CT scan of the 
thorax (71250) performed on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 8, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you rendered medically necessary services in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 office visit (99213) provided on June 8, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit provided on April 13, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the plan provides Medicare rules but does not 
detail why this claim is being denied falls within those rules. The plan has not substantiated their denial. 
Therefore, we decided that the Plan has to pay for the emergency department visit provided on April 13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 7, 
2020, to February 9, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that the charges 
are too high. 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 $250 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from February 7, 2020, to February 9, 2020. Therefore, you are responsible 
to pay a $250 copayment for days 1-2 (February 7, 2020, to February 8, 2020). $250 (copayment) x 2 (inpatient 
days) = $500.  
 
You have been asked to pay the total copayment amount of $500 for an inpatient hospital stay. An inpatient 
hospital stay falls within the 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 
copayment for an inpatient hospital stay from February 7, 2020, to February 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for speech therapy services you received from 
March 9, 2020, to March 16, 2020. 
 
You asked the Plan to waive the copayments for the speech therapy services. You say that you did not have 
speech therapy.  You also said that you were told that speech therapy was only $15. The Plan denied your 
request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each outpatient therapy visit.  
 
You have been asked to pay a $40 copayment for the speech therapy services. The speech therapy services fall 
within the outpatient therapy visit benefit category. The medical records from these dates of service clearly 
indicate that you received speech therapy services on March 9, 2020, March 11, 2020, and March 16, 2020. 
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 speech therapy services you received from March 9, 2020, 
to March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient psychiatric care provided from June 5, 2020 to June 18, 2020. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that you obtained authorization 
for this admission. The Plan denied your request. The Plan says that the denial of payment for this inpatient 
stay is correct, because the records do not support the necessity of inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that this inpatient stay meets the Medicare criteria for coverage. Our physician reviewer found 
based upon the records provided, it was expected that this enrollee would improve in a reasonable period of 
time as she did have dangerousness to self with the thought of overdose. She did not have any homicidal, 
auditory or visual hallucinations, or behaviors threatening acute safety. She was cooperative and compliant 
with treatment. It did appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care, rather than a lower level of care as she had dangerousness to self. The Plan's denial of 
inpatient psychiatric services is inappropriate. Active treatment was taking place. The services were reasonably 
expected to improve the enrollee's condition or for the purposes of diagnosis. The record does not include an 
individualized treatment plan; however, the entire record is not present. The records were supervised and 
evaluated by a physician. 
 
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 psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric care provided from June 5, 2020 to June 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that you need a bottom partial denture. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
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 pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on June 18, 2020. 
 
You asked the Plan to pay for the local anesthesia. 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the nebulizer provided from January 26, 
2020, through June 26, 2020. 
 
You asked the Plan to waive the deductible for the nebulizer. You say that you weren't informed about a cost or 
that you were renting it. You say that you don't know why medically necessary equipment isn't paid for. The 
Plan denied your request. The Plan says the deductible applied correctly. 
 
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 your combined in-network and out-of-network medical deductible is $290. This 
is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. 
Until you have paid the deductible amount, you must pay the full cost for most of your covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Durable Medical 
Equipment (DME) and Related Supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $290 deductible applies to durable medical equipment. This cost sharing is a 
contractual obligation that had not been met at the time the nebulizer was received from January 26, 2020 to 
June 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the nebulizer 
provided from January 26, 2020, through June 26, 2020.  
 
Your complaint about rental fraud is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for a Freestyle Libre continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve CGM sensors. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these supplies is correct, because the enrollee is only 
injecting insulin two times per day which does not meet Medicare criteria for a therapeutic CGM. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM sensors. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested CGM sensors. Our physician reviewer found 
the enrollee is not insulin-treated with three or more daily injections of insulin. She is on Lantus insulin twice 
daily. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CGM sensors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sensors for a Freestyle Libre continuous glucose monitor (CGM).