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

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for right sided weakness and was treated for a stroke. His medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 17, 
2020, through June 19, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be 
covered. 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 $370 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $370 copayment per day for days 1-5 for inpatient hospital care. This service 
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 
inpatient hospital care provided on June 17, 2020, through June 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided January 20, 2020, to 
January 27, 2020. 
 
You asked the Plan to pay for inpatient mental health care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says services could have been provided at a lower 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 mental health care. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found it did not appear that the 
services were reasonably expected to improve the patient?s condition or for the purpose of diagnosis. This 
patient was treated under an individualized treatment plan found in the record. It did appear that the records 
were supervised and evaluated by a physician. Based upon review the records provided, the admission of this 
patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be 
a danger to himself or others and was without agitation or aggression without perceptual disturbance including 
auditory or visual hallucinations. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided January 20, 2020, to January 27, 2020.
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. The Plan denied your request. The Plan says you are 
receiving appropriate in-patient acute care, and do not require a transfer to a LTACH. 
 
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 documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our reviewer found that there 
are no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the Health Plan. Our physician reviewer also found that consequently, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and 
condition 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 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 waive the copayment for debridement, subcutaneous tissue (includes 
epidermis and dermis (11042) provided June 17, 2020 to July 1, 2020. 
 
You asked the Plan to waive the copayment for the debridement services. You say that you paid $20 and have 
been paying $20 for the wound clinic care you receive. You do not agree with the processing. The Plan denied 
your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence 
of Coverage. 
 
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 $225 
copayment per visit for Medicare covered outpatient surgery or procedure at hospital facility.  
 
You have been asked to pay $225 copayment for the debridement services. The debridement services fall 
within the Outpatient surgery, including 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 debridement, subcutaneous 
tissue (includes epidermis and dermis (11042) provided June 17, 2020 to July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited problem focused oral exam (D0140) and the 
periapical x-ray (D0220) provided on July 20, 2020. 
 
You asked the Plan to pay for dental codes D0140 and D0220. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these dental services are not 
covered under your dental 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, dental codes D0140 and D0220 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited problem focused oral exam (D0140) and the periapical x-ray (D0220) provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on January 23, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on January 23, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the assay of Homocysteine laboratory test received. 
 
You asked the Plan to pay for the assay of Homocysteine. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the assay of Homocysteine by a contract provider. The file does not show that the Plan 
provided notice that the assay of Homocysteine would not be covered. Under Medicare rules, this means the 
assay of Homocysteine is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the assay of Homocysteine laboratory test received.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 13, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network, the services were not referred by a network 
provider or rendered in a participating facility, and the services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 13, 2020, 
by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 3, 2020, and July 27, 
2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
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 physician's services provided on July 3, 2020, and July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided from 
January 9, 2020, to April 8, 2020. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not be 
charged the copayments because of the pandemic. You say you have had regular office visits. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 $45 
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's 
office.  
 
You have been asked to pay a $45 copayment for each of the specialist office visits. The specialist office visits 
fall within the 'Physician/Practitioner Services, Including Doctor's Office Visits' benefit category. The record 
shows the start date of the Plan's copayment waiver policy began on May 11, 2020. Therefore, the specialist 
office visits on January 9, 2020 and April 8, 2020 do not qualify. 
 
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 specialist office visits provided from January 9, 2020, 
to April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered on 
September 16, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were in conjunction 
with your annual wellness visit and should have no copayment. 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 $10 
copayment for Medicare-covered laboratory tests.  
 
Review of the file shows that you received laboratory services on September 16, 2020. These services fall 
outside of the scope of an annual wellness visit. You have been asked to pay a $10 copayment for these 
services. These services fall within the Medicare-covered laboratory tests 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 laboratory services rendered on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional chiropractic visits. 
 
You asked the Plan to pre-approve ten additional chiropractic visits. You say that continued services are 
medically necessary. The Plan denied your request. The Plan says the enrollee no longer needs these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 ten additional chiropractic visits. Our 
reviewer says that the criteria for coverage of these services have not been met. Our physician reviewer found 
there is no evidence from the submitted documentation that clinical improvement has occurred or will likely 
occur with additional chiropractic treatments. This is maintenance treatment and is not allowed per Medicare 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten additional chiropractic visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ten additional chiropractic visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 18, 2020 by 
an out of network provider. 
 
You asked the Plan to pay for the wound care services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 wound care services provided on September 18, 2020 by an out of network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 23, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 23, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visits (99203, 99213, 99212) x-rays (72100, 
72070) chiropractic manipulation of one or more of the extra-spinal regions (98943) application of modalities 
(97035, 97014) therapeutic procedures (97110) provided May 26, 2020 to July 27, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that your appeal relates to the considerable 
time and expense of surgery, drugs, recovery and physical therapy that you were spared because this 
chiropractic care worked. The Plan denied your request. The Plan says these services are not covered as the 
services are not for manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for outpatient office visits (99203, 99213, 99212) x-rays (72100, 72070) 
chiropractic manipulation of one or more of the extra-spinal regions (98943) application of modalities (97035, 
97014) therapeutic procedures (97110) provided May 26, 2020 to July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ear lobe repair surgery. 
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because the 
requested surgery is medically necessary. The Plan denied your request. The Plan says the requested service is 
cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
ear lobe repair is not medically necessary. Our reviewer found the requested service is cosmetic in nature. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ear lobe repair surgery.