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

We decided that the Plan does not have to pay for subsequent hospital care (99232 and 99233) provided by
August 22, 2019 through August 27, 2019.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says these services are part of the global
surgery package.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We asked our coder 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 subsequent hospital care. Our reviewer says that The
documentation was reviewed and does not support an unrelated service to the surgical service provided on
August 22, 2019. Our reviewer found CPT codes 99232 24 and 99233 24 do not meet criteria for
reimbursement consideration.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for subsequent hospital care (99232 and 99233) provided by August 22, 2019
through August 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 10, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the referring provider is also out-of-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 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 physical therapy provided on April 10, 2019 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 the x-ray, laboratory services and CT scan
provided on December 3, 2019 and December 6, 2019.
You asked the Plan to waive the copayment for the x-ray, laboratory services and CT scan. You say that these
are preventive services not treatment of an existing condition. The Plan denied your request. The Plan says the
copayments 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 $35
copayment for x-rays, a $25 copayment for laboratory tests and a $195 copayment for other outpatient
diagnostic tests.
You have been asked to pay a total of $255 for the x-ray, laboratory services and CT scan.
The x-ray, laboratory services and CT scan fall within the "Outpatient diagnostic tests and therapeutic services
and supplies" benefit category. The x-ray, laboratory services and CT scan are considered diagnostic services.
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 x-ray, laboratory services and CT scan provided on
December 3, 2019 and December 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 20, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because
this was an emergency. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for an ER visit. An ER visit 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 an ER visit provided on October
20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 21, 2019.
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 has network providers
available who can provide 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 December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 under
chiropractic care.
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says treatment
available for coverage under chiropractic care is only for spinal manipulation.
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 services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the medical services provided on October 28, 2019 under chiropractic
care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 27, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composites. You say that you were in the process of being treated when you went to one of your appointments and was told that your insurance plan would not cover your ongoing treatments. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on January 27, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the Retacrit is medically necessary. The Plan denied
your request. The Plan says coverage has already been approved under the prescription drug benefit. Coverage
is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Retacrit.
Benefits for Retacrit may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for transplant travel and lodging expenses provided
from November 5, 2019 to November 8, 2019.
You asked the Plan to reimburse you for the transplant travel and lodging expenses. You say that the trip was
required by the facility doctor as a follow-up to a visit for prior stem cell transplant treatment. You say that you
have been reimbursed for the seven previous trips and that the trips are medically required. The Plan denied
your request. The Plan says are eligible for reimbursement for transplant related travel up to $125 per day for
one year, post-transplant. You were eligible for transplant related travel and lodging reimbursement from June
5, 2018 through September 14, 2019.
The contract with the Plan says that if the Plan provides transplant services at a location outside of the pattern
of care for transplants in your community and you chose to obtain transplants at this distant location, the Plan
will arrange or pay for appropriate lodging and transportation costs for you and a companion. The Plan's
Transplant Travel Reimbursement Guidelines states that the enrollee has one year (365 days) from the day of
the transplant to send the Plan the required information to be reimbursed.
We looked at the file and Plan's rules. The file shows that your transplant occurred on September 14, 2018.
You were eligible for transplant related travel and lodging reimbursement from June 5, 2018 through
September 14, 2019. Based on this information, we decided that the Plan's rules for coverage of the transplant
travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to reimburse
you for transplant travel and lodging expenses provided from November 5, 2019 to
November 8, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
services are medically necessary. Our physician reviewer found the enrollee does require skilled nursing or
therapy services on a daily basis. This enrollee does meet severity of illness or intensity of service criteria for
an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide non-emergent transportation to physician appointments.
You asked the Plan to provide non-emergent transportation. You say that you live far removed from a lot of services and travel is not easy. The Plan denied your request. The Plan says criteria for medical necessity, to use non emergent transportation, has not been met.
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 routine transportation in a wheelchair van or stretcher van when medically appropriate. We looked at your request, the records in the case file, and the rules. 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 provide non-emergent transportation to physician appointments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that this is the only provider who can
provide these services. The Plan denied your request. The Plan says there are in-network providers who can
provide these services.
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/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a specialist office visit to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
January 30, 2020 to February 3, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. 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 DME and related supplies.
You received DME and related supplies on January 30, 2020. The total allowed amount is $239.40 and 20% of
that is $47.88.
You received DME and related supplies on February 3, 2020. The total allowed amount is $98.80 and 20% of
that is $19.76.
The total amount you owe is: $67.64.
You have been asked to pay the total coinsurance amount of $67.64 for DME and related supplies. DME and
related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies provided from January 30, 2020 to February 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 6, 2020 to November 4, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 6, 2020 to November 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that more services are needed to continue with home
care. The Plan denied your request. The Plan says home health services may be needed when you need a skilled
nurse to care for an illness.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 visits. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, to establish/perform a maintenance program to maintain the patient's
condition and/or prevent deterioration. The documentation does not reveal complex wound care, IV antibiotics
or other SN need. The records do not show that the enrollee's functional level requires additional skilled
therapy services to effectively provide treatment, care, and/or services in order to improve the enrollee's level
of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or
prevent deterioration. The enrollee has had prior PT and the documentation does not reveal that the enrollee
needs the ongoing skills of a therapist. There is no evidence of a new injury and the enrollee should have been
educated on a home exercise program and safety with the prior completed PT sessions.
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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve home health visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure.
You asked the Plan to pre-approve a Vertiflex procedure. You say that the service is necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the veriflex device is experimental for use in the spine. More research is needed to
show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth #10.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says that there is not
pathologic destruction to the tooth involving four or more surfaces and at least 50% of the incisal edge. The
Plan also says that placing a crown on tooth #10 is not reasonable or necessary, and does not meet the coverage
criteria under the enrollee's supplemental benefits.
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 the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that the
service meets the Plan's coverage criteria. Our physician reviewer found due to the significant carious
breakdown and existing restoration, tooth #10 meets the criteria for coverage for a crown (D2750) to restore it
to adequate function and strength.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to preapprove
a crown (D2750) for tooth #10.
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.