Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dental services you received. 
 
You asked the Plan to waive the dental services. The Plan denied your request. The Plan says you are 
responsible for the copayment. 
 
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 services are subject to a 
cost share responsibility. The requested preventive dental services require a $35 copayment. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the dental services you received.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2020, V2100, V2750) provided on July 23, 
2020. 
 
You asked the Plan to pay for eyeglasses. You say that you should be reimbursed $200 according to your 
contract. The Plan denied your request. The Plan says these items are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine vision exam and refraction per year. 
 
We looked at the file and the Plan's rules. The items at issue are not covered under the Plans supplemental 
vision benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2020, V2100, V2750) 
provided on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health, and home physical therapy, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
The enrollee was admitted for back pain after a fall. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of scar tissue from hip or pelvis (CPT Code 
27299). 
 
You asked the Plan to pre-approve the service. You say that you are in pain and cannot sleep at night due to 
pain in your right hip. The Plan denied your request. The Plan says the service is considered experimental and 
investigational. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure and device TX1 (tenex health) for ultrasonic tenotomy is an FDA 
approved device, however, without any high level literature to support its efficacy, durability for use in chronic 
hip pain. It is therefore considered investigational at this time for the intended treatment for removal of scar 
tissue from the hip. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of scar tissue from hip or pelvis (CPT Code 27299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for breast reconstruction surgery provided. 
 
You asked the Plan to waive the coinsurance for breast reconstruction surgery. You say that you disagree with 
the charges. 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received breast reconstruction surgery. The total allowed amount is $6,079.37 and 20% 
of that is $1,215.87.  
 
You have been asked to pay the total coinsurance amount of $1,215.87 for breast reconstruction surgery. Breast 
reconstruction surgery falls 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 coinsurance 
for breast reconstruction surgery provided.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 20, 2020, to 
September 23, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the documentation supports that 
inpatient admission was medically necessary and reasonable for this enrollee. The Plan denied your request. 
The Plan says that this enrollee's care did not meet medical necessity criteria for acute inpatient hospital level 
of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was transferred ED to ED for work up of ischemic stroke. The enrollee arrived 
non-verbal and not responsive to verbal stimuli or commands after having received Ativan 2mg IV for 
agitation. Admitted for acute stroke with facial droop & HTN emergency. Blood pressure returned to 
acceptable limits within observation period. CT scan negative for acute pathology (finding noted moderate 
atrophy). The review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 20, 2020, to September 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services (93798) 
received. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you were told you 
would not be charged a 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 $40 
copay for each Medicare-covered cardiac rehabilitation visit. 
 
You have been asked to pay $720 (18 x $40 copayment) for cardiac rehabilitation services. These services fall 
within the Cardiac rehabilitation 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 cardiac rehabilitation services (93798) received.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on July 6, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code HCPCS G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 drug testing services (HCPCS 
G0483) provided to the enrollee on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 18, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 12, 2019.
Appeal type: Imaging
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 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation to an out of network provider. 
 
You asked the Plan to pre-approve routine transportation to an out of network provider. You say that if the Plan 
does not approve your request for transportation, the decision will interrupt your treatment. The Plan denied 
your request. The Plan says that there is no approved referral on file for the out-of-network provider. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers unlimited routine transportation trips to a plan-approved location.  
 
We looked at your request, the records in the case file, and the rules. The file indicates you are not requesting 
transport to a plan-approved location. Based on this information, we decided that the Plan?s rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation to an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine-Prilocaine cream. 
 
You asked the Plan to pre-approve Lidocaine-Prilocaine. You say that this service is medically necessary. The 
Plan denied your request. The Plan says all drugs used for the treatment of end stage renal disease are included 
in a bundled payment to the dialysis facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine-Prilocaine cream.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for rhythm electrocardiogram (ECG) (93040) 
and abdominal ultrasound (76705) received September 1, 2020. 
 
You asked the Plan to waive the copayments for diagnostic tests. You say that these services were received 
during your basic Wellness Visit and therefore should be free. The Plan denied your request. The Plan says 
Wellness Visits do not include lab tests, radiological tests or non-radiological diagnostic tests or diagnostic 
tests. 
 
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 $20 
copayment for Medicare-covered non-radiological diagnostic services, and a $110 copayment for each 
Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician?s office or at 
a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay an $11.48 copayment for a rhythm ECG (93040), and a $59.99 copayment for an 
abdominal ultrasound (76705). A rhythm ECG (93040) and an abdominal ultrasound (76705) 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 copayments for a rhythm electrocardiogram (ECG) (93040) and abdominal ultrasound (76705) 
received September 1, 2020.
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 the clinical information provided 
supports the LTACH level of care. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital. 
 
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 she is currently receiving care. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 21, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because it is the 
responsibility of the hospital staff to verify eligibility. The Plan denied your request. The Plan says non-urgent 
services should be from network providers who are contracted with the member?s health plan and listed in the 
Provider Directory. 
 
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 the medical services provided on January 21, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for inpatient hospital services provided from 
June 9, 2020, to June 16, 2020. 
 
You asked the Plan to adjust the copayment for the inpatient hospital services. You say that you were not 
discharged The Plan denied your request. The Plan says you were charged the copayment correctly and the 
additional days stayed did not affect your total copayment obligation. 
 
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 $275 
copayment per day for days 1-4 for Inpatient Hospital Care.  
 
You have been asked to pay a $1110 copayment per day for days 1-4 for the inpatient hospital services. The 
inpatient hospital services fall within the Inpatient Hospital Care benefit category. You have a $0 copayment 
for days 5-90. The medical notes indicate you were not clear for discharge before June 14, 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 adjust the copayment for inpatient hospital services provided from June 9, 2020, to June 16, 
2020.